Test 3 Flashcards
Rosacea pop
30-50, female
rosacea cause
Demodex mite may play a role
terrain, genetics, poor digestion, toxic bowels
rosacea sx
- mainly central face
- rhinophyma (M)
- erythema
- telangiectasia
- papulopustular, nodules, no comedones
rosacea associated conditions
- 3x migraines
- iritis
- scleritis
- keratitis
- chalazia
- blepharoconjunctivitis
rosacea TX
topical metronidazole: palliative
azelaic acid
benzoyl peroxide/clindamycin
oral antibiotics
sodium sulfacetamide
topical permethrin
Oral isotretinoin (Accutane)
low-dose doxycycline
topical tretinoin
anti-inflammatory diet
digestive enzymes, probiotics
acupuncture
homeopathy
Perioral Dermatitis pop
16-45, women
Perioral Dermatitis cause
unknown, aggravation by fluoride and sodium lauryl sulfate
terrain
Perioral Dermatitis sx
papulopustular on erythematous base
occasional itching, burning, or feeling of tightness
Perioral Dermatitis TX
topical-metronidazole, erythromycin, avoid topical glucocorticoids
Systemic- minocycline, doxycycline, tetracycline
avoid toothpaste with fluoride and sodium lauryl sulfate
anti-inflammatory/elimination diet
sauna, fasting
Botanical (Topicals): azelaic acid, green tea, tea tree oil, Calendula succus
Botanical (Internal): Silymarin, Berberine (barbarry, coptis, oregon grape, goldenseal), Chaseberry, Indian Gooseberry
Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula
Supplements to consider zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D
Hidradenitis suppurativa RF
Obesity
Female sex
Smoking
Acne vulgaris
Inflammatory bowel disease
Low zinc level
SAD
Hidradenitis suppurativa SX
Painful, papules and deep-seated nodules
open comedones with 2 or more openings to the surface in intertriginous areas
tender lesion in axillary, inguinal, intermammary and/or anogenital region
symmetrical
early Hidradenitis suppurativa symptoms
- erythema
- burning
- itching
- discomfort
- hyperhidrosis
mild hidradenitis suppurativa sx
- solitary nodule
- minimal pain
- no abscess
moderate hidradenitis suppurativa sx
- multiple recurrent nodules
- pain affecting activities of daily living
- discharge or drainage
- abscess formation
severe hidradenitis suppurativa sx
- diffuse abscess formation
- chronic draining sinus tracts
- chronic inflammation and scarring
hidradenitis suppurativa test
consider-bacterial culture
biopsy
hidradenitis suppurativa standard of care
tralesional injections of triamcinolone
Incise and drain acute abscesses
Oral antibiotics
Prednisone
Oral isotretinoin (Accutane)
mild/moderate hidradenitis suppurativa TX
- Topical/oral antibiotic
- Consider surgical drainage
- Lifestyle change (Acne protocol)
severe hidradenitis suppurativa TX
- topical/oral antibiotic
- Consider dapsone and/or prednsone
- Referral for surgical consult
- Lifestyle change (Acne protocol)
hidradenitis suppurativa naturopathic tx
loose clothing
avoidance of heat, humidity, shaving, depilation, deodorants
warm compresses
elimination/anti-inflammatory diet
Detox: fasting, sauna, chelation
Botanical (Topicals): azelaic acid, green tea, tea tree oil, Calendula succus
Botanical (Internal): Silymarin, Berberine, Chaseberry, Indian Gooseberry
Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula
Supplements: zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D
Contact Irritant Dermatitis cause
- Related to irritant exposure; anyone would have a similar reaction
- lime
- lip licking
- oven cleaner
- diesel mechanic chemicals
- diaper
Contact Irritant Dermatitis RF
Strong skin irritant (acid, alkali, phenol)
Cumulative exposure degreasing protective lipid barrier on skin (i.e. dish pan hands)
White skin
History of Atopic Dermatitis
Occlusion (i.e. wet boots)
Mechanical irritant (i.e. brick layer)
Contact Irritant Dermatitis sx
Burning and pain
Localized well-defined, redness, papules, swelling, blistering (vesicles/bullae)
Contact Irritant Dermatitis DX
Natural light-Magnifying glass (10-20X)
Check for infection, lymph nodes
Culture if you suspect bacteria, virus, etc
10% KOH to R/O fungus
Woods lamp
Examine whole body
“Patch testing”, allergies testing, biopsy
Contact Irritant Dermatitis prevention
Avoid irritant or caustic chemical(s) by wearing protective gear
If contact does occur, wash with water or weak neutralizing solution
Barrier creams
Contact Irritant Dermatitis TX
powder (“Country Comfort Baby Powder”), Ointments (Calendula, Comfrey, vitamin A&D)
use wet soaks containing tap water, saline, colloidal oatmeal
wet dressing using gauze soaked in Burrow’s solution
honey, olive oil and beeswax mixture
Topical Corticosteroids
5% urea cream
oral corticosteroids
Contact Allergic Dermatitis cause
- linalool
- Nickel sulfate(10-20%)
- Methylisothiazolinone
- Balsam of Peru
- Fragrance mix
- Thimerosal
- Sodium gold thiosulfate
- Formaldehyde
- Quaternium-15
- Cobalt chloride
- Bacitracin
- limonene
- poison oak or ivy
- chromium
- propolis
Type IV hypersensitivity
Contact Allergic Dermatitis SX
erythema, scaling, skin swelling, and sometimes blistering and ulceration
pruritus
burning pain
vesiculation to severe swelling with bullae
Contact Allergic Dermatitis DX
Natural light-Magnifying glass (10-20X)
Check for infection, lymph nodes
Culture if you suspect bacteria, virus, etc
10% KOH to R/O fungus
Woods lamp
Examine whole body
“Patch testing”, allergies testing, biopsy
Poison Ivy sx
- vesicles
- linear lesions
- bullae
Poison Ivy Tx
- Wash entire body with copious amounts of water
- Barrier creams (i.e. Stokogard, Ivy-block)
- Use Tecnu cleanser to remove urushiol
- Clothing, pets, etc need to be washed-wear vinyl gloves
- Cool compress-water, water/vinegar, saline
- topical or oral corticosteroid
- Antihistamine
- Trim fingernails
- Blow dryer-dries lesions, relieves itching
- Calendula lotion
- Calamine (zinc and ferric oxide)
- Burrow’s solution (aluminum acetate)
- Etoh, Comfrey, mugwort and sea salt
- Oatmeal (Aveeno), starch, or vinegar bath
- Aloe gel/green clay
- Stellaria, Plantago, Impatiens, Grindelia, Sambucus, Hamamelis, Echinacea, lemon
- Homeopathy, acupuncture and moxa
Atopic Dermatitis pop
children
Atopic Dermatitis cause
inflammation of dermis and epidermis caused by a combination of immune system activation, genetics, environmental triggers, and stress
Atopic Dermatitis Sx
pruritus
cubital fosa, popliteal fossa, face, chest, back of arms,
infantile Atopic Dermatitis
- face, scalp, extensor surface
- child 2 month- 2 years
- red, finely vesicular, oozing, crusted, extremely pruritic
- excoriation and secondary infections
Childhood Atopic Dermatitis
- 2-12 yo
- antecubital and popliteal fossae, post neck
- erythema, papules, scaling, lichenified, patches of hypopigmentation, hair loss
- develop allergic rhinitis and asthma
Adult Atopic Dermatitis
- extends to neck, upper chest, hands, feet
- marked drying resembling ichthycosis
- intense pruritus
- itch-scratch-rash cycle
- Dennie-morgan infraorbital fold, thinning lateral eyebrows
Atopic Dermatitis associated conditions
- Cataracts
- Chelitis
- conjunctivitis
- Facial pallor or erythema
- Food intolerance
- hand dermatitis
- Ichthyosis
- immediate skin test reactivity
- infections
- Infraorbital fold (Dennie-morgan lines)
- itching when sweating
- keratoconus
- keratosis pilaris
- nipple dermatitis
- orbital darkening
- Pityriasis alba
- White dermographism
- wool allergy
Atopic Dermatitis triggers
Temperature Change and Sweating
Decreased Humidity (worse in winter)
Excessive Washing- (esp with Soap)
Contact w/ Irritating Sub (wool, lanolin, smoke, etc.)
Contact Allergy- (consider patch testing)
Aeroallergens- (dust mites, pollen, animals, etc)
Microbic Agents- (staph aureus, Pityrosporum)
Food- (see diet)
Reduced cAMP (polyamines, lack of exercise)
Emotional Stress- (recommend mediation)
Atopic Dermatitis ND TX
- Bleach bath or bath
-phage topically - humidity in the house
- Light therapy
- oral Vit d
Diet - ant-inflammatory diet
- elimination diet: reduce eggs, peanuts, milk, fish, soy, and wheat
- fasting and vegetarian diet
Supplements/Herbs - omega-3
- Oolong tea
- Arctium Lappa
- Korean red ginseng
- Perilla leaf-
- St John’s wort
- Chinese herbs to clear heat/dry damp – Rhubarb, coptis, scute, phellodendron
- probiotics
- glutamine
Atopic Dermatitis TX
- Topical steroids
- oral steroids
- emollients
- antimicrobial
- topical clcineurin inhibitors
- cyclosporine
- azathioprine
-monoclonal antibody drug
Advantages of topical medications
- localized effect
- minimal systemic absorption
- avoids Gi and first-pass metabolism
Disadvantages of topical medication
- not an option for several compounds due to poor lipid solubility
- dosing is inaccurate
- formulation sensitives/localizes reactions
What effects the absorption of topical meds
- skin thickness at site of application
- total area of application
- frequency of application
- blood flow at the site of application
- chemical and physical properties of the drug and the vehicle
- warm, moist skin
Oral meds uses
- topical application is ineffective or unavailable
- systemic effects are desired
- topical application is impractical
Advantages of oral meds
- generally safe
- convenient
- economical
Disadvantages of oral meds
- some drugs have poor absorption
- systemic effects
- first-pass metabolism
- drug interactions
Advantages of Transdermal meds
- by pass first-pass metabolism
- convenient
- ideal for drugs that are lipophilic and have poor oral bioavailability
- ideal for drugs that are quickly eliminated from the body
Disadvantages of transdermal med
- localized dermal reactions
- has to be highly lipophilic
- may be delayed in delivery to the site of action
- limited to small dose
Corticosteroids MOA
suppression of eicosanoid synthesis by inhibition of phospholipase A2, suppression of immune cell activation and proliferation
Corticosteroids use
inflammatory lesions, including keloids, hemangiomas, acne cysts, stubborn psoriatic plaques, alopecia areata, etc.
acne
alopecia areata
atopic dermatitis
bites and stings
bullous pemphigoid
burns
route of administration of corticosteroids
topical
oral
intralesional
intranasal
AE of topical steroids
- atrophy, purpura
- telangiectasia
- facial eruptions
- hypopigmentation
- hypertrichosis
- withdrawal effects
- striae
- contact dermatitis
- worsening fungal infection
AE of oral steroids
- crushing’s syndrome
- adrenal suppression
- growth retardation in children
- increased intraocular pressure
- increased risk of nasal and pharyngeal Candida Infection
- the effects of long-term use on bone density and risk of fracture are not clear
Corticosteroids in pregnancy
high potency is associated with lower birth weight, considered safe during pregnancy and lactation, based on limited data
Which corticosteroid has the lowest potency?
hydrocortisone
what are the oral corticosteroid?
prednisone and prednisolone
Intralesional corticosteroid uses
keloids
hemangiomas
acne cysts
stubborn psoriatic plaques
alopecia areata
intralesional corticosteroid AE
atrophy
hypopigmentation
telangiectasia
sterile abscesses
Azaleic acid use
acne
rosacea
hyperpigmentation
Azaleic acid MOA
combined anti-inflammatory, anti-bacterial, and keratolytic effects, inhibition of tyrosinase
Calcineurin Inhibitors MOA
prevents activation of T cells don’t differentiate or become active
Calcineurin Inhibitors use
severe lichen planus, contact allergic dermatitis, dyshidrotic eczema, perioral dermatitis, psoriasis, pyoderma gangrenosum, and vitiligo
atopic dermatitis
severe psoriasis
Calcineurin Inhibitors risks
can lead to cancer for long term use
Calcineurin Inhibitors oral side effects
nephrotoxic
neurotoxic
Biologic DMARDs route of administration
injection
Biologic DMARDs MOA
block TNFa
Neosporin contains
bacitracin, neomycin, polymyxin B
Bacitracin MOA
cell wall synthesis inhibitor
Neomycin MOA
bacterial protein synthesis inhibitor
polymyxin B MOA
bacterial membrane disruptor
Mupirocin drug class
topical antibiotic
Mupirocin MOA
binds to tRNA and disrupts protein synthesis
Mupirocin use
MRSA
Impetigo
Benzoyl peroxide MOA
kills bacteria by creating reactive oxygen species
Benzoyl peroxide use
acne
Benzoyl peroxide route of administration
topical
Sulfacetamide MOA
inhibits folate synthesis
Sulfacetamide route of administration
topical
oral
Sulfacetamide Use
acne
seborrheic dermatitis
Erythromycin MOA
bind to bacterial ribosomes and inhibits protein synthesis
Erythromycin Route of Administration
topical
oral
Erythromycin use
acne
Erythromycin AE
significant GI upset
major inhibitor of CYP3A4
hepatotoxicity
arrhythmia
Clindamycin MOA
bind to bacterial ribosomes and inhibit protein synthesis
Clindamycin route of administration
topical
oral
Clindamycin use
acne
other infections
Clindamycin AE
C. difficile
Metronidazole MOA
binds to bacterial DNA preventing protein synthesis and inducing DNA breaks
Metronidazole Route of Administration
oral
topical
Metronidazole side effects
carcinogen
Metronidazole cautions
ethanol use can cause abdominal pain, nausea, vomiting, headache, flushing
Dapsone use
Acne
Bullous pemphigoid
Pemphigus vulgaris
Dermatitis herpetiformis
Lichen planus
Pustular psoriasis
Pyoderma gangrenosum
Dapsone route of administration
oral
topical
Diclofenac Sodium drug class
NSAIDs
Diclofenac Sodium use
actinic keratosis
Diclofenac Sodium Mode of Administration
gel
acne vulgaris pop
12-25
acne vulgaris pathophysiology
Outlet narrows due to proliferation and accumulation of keratinocytes and skin edema
Sebum (composed of lipids and cell fragments) builds up in blocked follicle
Cutibacterium acnes(formerly Propionibacteriumacnes) lives off sebum and proliferates in comedone
Inflammation of comedone results from leakage of sebum into the dermis and secretion of proinflammatory mediators, chemokines, and degradative enzymes by C. acnes
acne sx
papules or pustules or nodules or cysts red and central core
face, trunk, arms, back, upper chest, shoulders
acne tx ND
Diet: 100% grass fed pastured or wild meats, fish and eggs, vegetables, fruit, nuts, seeds, and tubers
Eliminate/reduce processed foods, diary, grain fed meat, chocolate, sunflower seeds, salt
Anti-inflammatory/elimination diet
Detox: fasting, sauna, chelation
Botanical (Topicals): azelaic acid, green tea, tea tree oil,
Calendula succus
Botanical (Internal): Berberine (barbarry, coptis, oregon grape, goldenseal), Chasteberry, Indian Gooseberry
Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula
Supplements to consider zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D
Acne Standard of Care
Seborrheic Dermatitis cause
Pityrosporum yeast (Malassezia), genetics, stress and dietary factors effect onset of disease
Pityosporum/Malassezia lipase activity releases inflammatory free fatty acids and activates the alternative complement pathway
Seborrheic Dermatitis pop
males>female (infancy, 20-50y.o.)
Seborrheic Dermatitis sx
The rash is red and scaly, except in skin folds, where it is red, smooth and glazed.
Sticky crusts and fissures are common when ear and scalp are involved. Dry or greasy scales.
Infantile (cradle cap) and adult forms (i.e. dandruff)
Scalp, eyebrows, eyelids, nasolabial fold, paranasal area, ears, sternum, inframammary fold, axilla, pubic area, gluteal and inguinal fold, and umbilicus
Seborrheic Dermatitis TX
Anti-inflammatory/elimination/detox diet
Zinc
B complex
niacin
biotin
EFA’s
Heliotherapy
Hydrotherapy, acupuncture, homeopathy, mediation
Topical
– Honey with water
- Shampoo: Biotin, selenium sulfide, zinc pyrithione, ketoconazole, tar, tea tree oil
- Gel: Aloe vera or metronidazole
- Cream: hydrocortisone, sulfur, pimecrolimus
- Eyelids: dilute baby shampoo on cotton swab
Pompholyx/ Dyshidrotic Eczema pop
female =male, 12-40
Pompholyx/ Dyshidrotic Eczema cause
Unknown etiology-possible association with stress, allergens, metals (Ni,Co,Cr)
Pompholyx/ Dyshidrotic Eczema sx
sudden onset of deep-seated pruritic, clear “tapioca-like” vesicles on palms and sides of fingers; later, scaling fissures, and lichenification can occur
2-4 weeks
can have infection associated
unilateral
Pompholyx/ Dyshidrotic Eczema TX
Anti-inflammatory/elimination/detox diet (Metals)
Wet astringent compresses with dilute vinegar, Hamamelis, or Burow’s soln (aluminum acetate)
Follow with Calendula and stellaria in a hypoallergenic cream (i.e. Eucerin, Nivea, etc.)
Heliotherapy 5min-1 hour daily
Acupuncture, homeopathy, herbal, meditation
Topical or intralesional triamcinolone
Prednisone, antibiotics with infection
“Id reaction”/Autosensitization Dermatitis cause
“Id reaction”/Autosensitization Dermatitis cause
release of cytokines that develop in a distal primary dermatitis, i.e. tinea pedis, stasis derm, etc.
“Id reaction”/Autosensitization Dermatitis sx
An itchy, dyshidrotic-like vesicular eruption on the fingers, forearms, thighs, legs, trunk
unilateral
“Id reaction”/Autosensitization Dermatitis tx
find the main cause
prednisone
Lichen Simplex Chronicus pop
Lichen Simplex Chronicus cause
unknown, stress,
Created and perpetuated by constant scratching and rubbing (itch-scratch-rash)
Initial cause may have been ACD, ICD, fungal, bug bite
Lichen Simplex Chronicus sx
Very thick plaques
Usually just one lesion
Severe itching
Last indefinitely
Recurs frequently
Lower legs, Scrotum, vulva, anus, pubis, Wrists, ankle, elbow, Upper eyelids, Back, side of neck, Ear-orifice and fold, and Scalp-picker’s nodules
Lichen Simplex Chronicus tx
Must stop “itch-scratch-rash” cycle
Occlusive barrier-unna (Zn oxide dressing-1 wk) and dome (Al) paste boot
Tranquilizer (herbal, nutritional), no coffee
Anti-inflammatory/elimination diet
Psychotherapy, hypnosis, relaxation exercises, mediation, homeopathy
Acupuncture
Topical glucocorticoid gauze dressing
Topical/intralesional Triamcinolone
Other options-Topical doxepin, oral hydroxyzine
Nummular Dermatitis Sx
coin-shaped plaques
Initial onset-closely grouped, small vesicles and papules that coalesce into plaques
Extensor aspects of extremities, buttock, breast, and posterior trunk
weeks to months
itching moderate to severe
Nummular Dermatitis Tx
- Topical steroids
- oral steroids
- emollients
- antimicrobial
- topical clcineurin inhibitors
- cyclosporine
- azathioprine
-monoclonal antibody drug
Nummular Dermatitis ND Tx
- Bleach bath or bath
-phage topically - humidity in the house
- Light therapy
- oral Vit d
Diet - ant-inflammatory diet
- elimination diet: reduce eggs, peanuts, milk, fish, soy, and wheat
- fasting and vegetarian diet
Supplements/Herbs - omega-3
- Oolong tea
- Arctium Lappa
- Korean red ginseng
- Perilla leaf-
- St John’s wort
- Chinese herbs to clear heat/dry damp – Rhubarb, coptis, scute, phellodendron
- probiotics
- glutamine
Asteatotic Dermatitis pop
elderly, northern cold climates, low humidity
Asteatotic Dermatitis Sx
Dryness of the skin
Erythema, inflammation, and scaling
Lower anterolateral legs, trunk, upper extremity
porcelain pattern
bilateral
Asteatotic Dermatitis TX
- Topical steroids
- oral steroids
- emollients
- antimicrobial
- topical clcineurin inhibitors
- cyclosporine
- azathioprine
-monoclonal antibody drug
Asteatotic Dermatitis ND TX
- Bleach bath or bath
-phage topically - humidity in the house
- Light therapy
- oral Vit d
Diet - ant-inflammatory diet
- elimination diet: reduce eggs, peanuts, milk, fish, soy, and wheat
- fasting and vegetarian diet
Supplements/Herbs - omega-3
- Oolong tea
- Arctium Lappa
- Korean red ginseng
- Perilla leaf-
- St John’s wort
- Chinese herbs to clear heat/dry damp – Rhubarb, coptis, scute, phellodendron
- probiotics
- glutamine
Stasis Dermatitis pop
women
Stasis Dermatitis cause
chronic venous insufficiency
HTN
diabetes
standing for long periods
FH
Stasis Dermatitis SX
lower extremities, associated with edema, varicosed and dilated veins, and hyperpigmentation
Stasis Dermatitis TX
Improve venous return thru cool water dressing, cool water walking, compression stockings, anti-inflammatory diet, herbs (ginkgo, aesculus, Centella)
Bland emollients(vasoline base)
Topical steroids
Oral antihistamines
Consider vein stripping or sclerotherapy
venous leg ulcers TX
unna boot
manuka honey
pycnogenol
walking
hydroxyzine MOA
blocking H1 receptors on afferent nerve fibers
hydroxyzine CI
older patients
Diphenhydramine MOA
blocking H1 receptors on afferent nerve fibers
Diphenhydramine route
oral
topical
Diphenhydramine CI
older patients
Hydroxyzine route
oral
antihistamines drugs
Hydroxyzine
Diphenhydramine
what are antihistamines use for in skin conditions
pruritis
antiviral drugs
acyclovir
valcyclovir
acyclovir and valcyclovir AE
headache
malaise
GI upset
acyclovir and valcyclovir use
HSV
HZV
acyclovir and valcyclovir route
topical
oral
acyclovir moa
affect viral replication
antifungal drugs
azoles
nystatin
gentian violet
griseofulvin
terbinafine
azoles
Ketoconazole
Fluconazole
fluconazole MOA
inhibit ergosterol synthesis
fluconazole use
most effective against Candida
Fluconazole route
oral
Fluconazole CI/Cautions
strong CYP2C19 inhibitor
moderate 2C9, 3A4/5, UGT inhibitor
Fluconazole AE
- GI disturbance
- hepatotoxicity
- drug interactions
Ketoconazole MOA
inhibit ergosterol synthesis
Ketoconazole route
oral
topical
Ketoconazole AE
oral and IV
- GI disturbance
- hepatotoxicity
- drug interactions
topical
- local hypersensitivity reactions
Ketoconazole use
Candidiasis
Tinea infections
Ketoconazole caution
strong 3A4 inhibitor
Nystatin MOA
binds to ergosterol in the cell membrane inducing instability, disrupt cell wall
Nystatin route
topical
oral (swish and spit)
Nystatin AE
oral
- GI disturbance
topical
- local hypersensitivity reactions
Nystatin use
Candida infections
oral candida
vaginal candida
Gentian Violet MOA
DNA binding preventing cell division
Gentian Violet use
topical for thrush, onychomycosis
active against both bacteria and fungi
Griseofulvin MOA
binds to microtubules, thereby preventing cell division
Griseofulvin route
oral
Griseofulvin use
dermatophytosis of the scalp and hair
Terbinafine route
topical
oral
Terbinafine use
- tinea pedis
- tinea corporis
- tinea cruris
- tinea versicolor
Oral
- fungal infections of the nail
- tinea capitis
antiparasitic
Permethrin
Ivermectin
Permethrin route
topical
Permethrin uses
rosacea
Ivermectin route
topical
oral
Ivermectin use
lice
scabies
rosacea- topical
Ivermectin AE
pruritis
lymphadenitis
arthralgia
fever
edema
GI upset
increase liver enzyme
antineoplastic agents
5-fluorouracil
5-fluorouracil moa
nucleotide analog that interferes with DNA synthesis, preventing cell proliferation
5-Fluorouracil route
topical
5-Fluorouracil use
actinic keratosis
superficial BCC
cutaneous warts
5-Fluorouracil AE
- Sinusitis
- Headache
- Pigmented changes
- Edema
- Skin erosion
- Erythema
- Drying
- Scaling
- pregnancy
chemical peels
glycolic acid
glycolic acid moa
acts as keratolytic
Glycolic Acid AE
skin irritation
pruritis
erythema
Glycolic Acid use
hyperpigmentation
Ethinylestradiol MOA
inhibits ovarian androgens production and may inhibit androgen action in the sebaceous gland
Ethinylestradiol use
acne
hidradenitis suppurativa
Ethinylestradiol route
oral
Ethinylestradiol AE
blood clots
Drospirenone use
acne
Drospirenone pharm class
progestins
Ethinylestradiol pharm class
estrogen
Levonorgestrel IUD CI
acne
hydroquinone moa
inhibits tryosinase
Hydroquinone route
topical
Hydroquinone AE
erythema
stinging
desquamation
Hydroquinone use
hyperpigmentation
Spironolatone MOA
blocks androgen receptors and inhibits androgen biosynthesis
Spironolactone use
acne
hirsutism
hidradenitis suppurativa
transgender care
Spironolactone AE
hypotension
hyperkalemia
Imiquimod moa
binds to TLE7/8 which activates NF-kappa-B, leading to a Th1 response
Imiquimod route
topical
Imiquimod use
actinic keratosis
warts
superficial BCC
Imiquimod AE
local inflammatory reactions
photosensitivity
systemic reactions
caution in patients with autoimmune disease
not used for oral, nasal, intravaginal, or ophthalmic uses
Keratolytics drugs
trichloroaceic acid
salicylic acid
methyl aminolevulinate
aminolevulinic acid
Trichloroacetic acid MOA
precipitation of intercellular proteins
Trichloroacetic acid route
topical- physician performed
Trichloroacetic acid AE
chemical burns if applied to health tissue
Salicylic acid MOA
solubilization of inter-cellular matrix, reducing cellular adhesions
Salicylic acid route
topical
Salicylic acid use
acne
callouses and corns
keratosis pilaris
psoriasis
warts
hyperpigmentation conditions
Salicylic acid AE
skin sensitivity and burning
tinnitus
confusion
hyperventilation
salicylate hypersensitivity reactions
Lidocaine use
pruritis
pain
Lidocaine route
topical
Lidocaine AE
seizure
cardia arrest
respiratory depression
retinoids drugs
tretinoin
isotretinoin
acitretin
Tretinoin MOA
bind to intracellular retinoic acid receptors and retinoid x receptors and bound complex causes changes in gene transcription
anti-inflammatory, keratolytic, and reduce sebum production
reduce post-inflammatory hyperpigmentation
Tretinoin route
topical
Tretinoin use
normalize follicular hyperkeratosis
acne
hidradenitis suppurativa
milia
psoriasis
rosacea
hyperpigmentation
Tretinoin AE
skin irritation
dryness
flakiness
pregnancy
Isotretinoin MOA
decreasing sebocyte proliferation and causing apoptosis of sebocytes
increase p53 inhibits IGF-1 signaling, inhibit sebocyte differentiation, sebocyte apoptosis, reduce inflammation
Isotretinoin route
topical
Isotretinoin use
serve recalcitrant nodular acne
cutaneous t-cell lymphomas
neuroblastomas
prevention of SCC
Isotretinoin AE
cheilitis
dry skin
dry eyes
pruritis
vision changes
hepatotoxicity
photosensitivity
increased triglyceride levels
myalgias
depression
IBD
pregnancy
Acitretin MOA
antiproliferative, anti-inflammatory, and normalizes keratinocyte differentiation
Acitretin use
severe psoriasis
Acitretin AE
pregnancy
calcipotriol moa
bind to Vit D receptors, inhibiting cell proliferation and enhancing cell differentiation
reduce inflammation by inhibiting T cell proliferation and production of cytokines
inhibits keratinocyte proliferation and abnormal differentiation
Calcipotriol route
topical
Calcipotriol use
psoriasis
Calcipotriol AE
skin irritation
hypercalcemia
Polymorphous Light Eruption pop
All races, Females>male, around age 20
Polymorphous Light Eruption cause
Delayed abnormal reaction to UV radiation
Spring, early summer – 2-24 hours after 1st exposure – last 7-10 days
Polymorphous Light Eruption sx
Morphologic skin types can vary: vesicles, papule, erythematous macules, plaques
Polymorphous Light Eruption TX
Prevention: sun block should be used, but not always helpful
beta-carotene, 60 mg tid 2 weeks before sun
Niacinamide, 2-3 g/day helped 60% of pts in one study
Vit B-6, 150-200 mg, taken 30 minutes before sun, or 100 mg/hr for 8-10 hours before sun (case reports-Gaby)
Consider antimalarial drugs
phototherapy
Drug-related Eczema cause
Any drug, nutriceutical or herb, almost without exception, is capable of causing a skin eruption.
Drug-related Eczema SX
Any sudden fixed, symmetrical, or generalized skin eruption should be questioned
Drug-related Eczema TX
identify and eliminate
psoriasis pop
white, 40, male and female, FH
Psoriasis trigger
physical trauma (koebner phenomenon)
infections
stress
systemic glucocorticoids, oral lithium, antimalarial drugs, systemic interferon, Beta blockers, alcohol
incomplete protein digestion
excessive animal protein consumption
food allergies/increased intestinal permeability
bowel toxemia
stressed liver
deficient EFA
deficient vit D and sunlight
Plaque psoriasis triggers
genetics
HLA types-HLA-B13, B17,Bw57, HLACw6
Alteration of the cell kinetics of Keratinocytes likely due to abnormal T lymphocyte function/communication
increased cell cycle
Plaque Psoriasis Sx
light-skinned: red or pink often silvery white scales
darker-skin: silvery white scale, violet,
papules and plaques, sharply marginated
Removal of scales-reveals punctate bleeding called auspitz’s sign
itching
plaque psoriasis complications
develop arthritis
nail pitting, oil spot lesions, onycholysis
guttate pop
child or young adult
guttate cause
group A streptococcal pharyngitis or viral infection
guttate sx
red, scaly, small, teardrop-shaped spots. It doesn’t normally leave a scar.
sudden onset
guttate psoriasis management
3-4 month self-resolve
no antibiotics
Pustular psoriasis sx
skin to redden, swell and become covered by tender, pus-filled blisters that are called pustules. The pus inside pustules is a noninfectious, whitish fluid.
hands and feet
inverse psoriasis sx
painful
skin folds, armpits, genitals, under breasts or buttocks
Erythrodermic psoriasis sx
peeling rash across the entire surface of the body
itch or burn
spreads quickly
Erythrodermic psoriasis cause
severe sunburn, infection, excessive alcohol consumption, taking or stopping oral steroids, skin trauma from surgery or injury, reaction to medication
Psoriasis TX
ID and eliminate triggers
reduce bowel toxemia
- bile acids
- HCL
- apple cider vinegar
- bitters
- healthy diet
- bioflavonoids
- Anit-inflammatory diet
- fasting
- vegetarian diet
- Vit A
- probiotics
- chelation
diet
- gluten free diet
- High intake of omega-3, fasting, low-calorie and vegetarian diets
- fasting
supplements
- Vitamin D2
- Fish oil
- Vitamin A
- Vitamin E
- Vitamin C
- Zinc
- Selenium
- Chromium
- Flavonoid extracts
- Bile acids
- Water-soluble fiber (psyllium, pectin, guar gum, etc.): 5g at bedtime (binds endotoxins, decreases bowel transit time)
Botanicals
- Milk Thistle
- curcuma longa
- aloe vera
- nigella sativa
- rubia cordifolia
- smilax china
- thespesia populnea
- wrightia tinctoria
- cassie tora
- scutellaria baicalensis
- pongamia pinnata
- taraxacum
- uritca
- capsaicin
- licorice
- chamomile
- EPO
- castor oil
- honey
Physical modalities
- phototherapy
- natural sunlight
- narrow-band UVB
- PUVA
Pharmaceuticals
- topical
- Vit D3
- steroids
- tar
- retinoids
- anthralin
- salicylic acid
- fumaric acid
- tacrolimus
- pimecrolimus
- internal
- methotrexate
- apremilast
- biologics
- retinoids
- cyclosporine
Pityriasis rosea cause
unknown
viral origin
Pityriasis rosea pop
10-35 yo
Pityriasis rosea sx
pruritus
Herald Patch (80%)1-10 cm, pre-dates the reminder of the other lesions by hours to 14 days
5% have fever, malaise, headache, and arthralgia
Pityriasis rosea DX
anti-streptolysin test
Pityriasis rosea tx
If mild-severe itch: natural sunlight, UVB, colloidal oatmeal, emollients, topical/oral antihistamines
Severe cases-oral steroids rarely
Acupuncture, homeopathy, herbal, diet, etc.
Lichen planus sx
purplish, itchy, flat bumps that develop over several weeks
skin, hair, nails, and mucous membrane
Lichen planus cause
fam hx, viral, bacterial, stress, drugs, liver disease
Lichen planus pop
30-60, females>males
Lichen planus SX
pruritic, planar (flat-topped), polygonal, purple papules, 2-10mm in diameter
Surface scales are lacy (reticulated) fine white lines called “Wickham’s striae”
wrists (mc), forearm, ankles, ant legs, lumbar regions, and genitals
Lichen planus TX
ID/Eliminate Triggering Factors
Diet Recommendations (anti-inflammatory diet, increased fish oil, high quality fats,)
Nutritional Supplements (Vit A, Vit E, Zinc, Quercetin, EPA, probiotics)
Physical modalities (phototherapy)
Topical Treatments (topical steroids, cardiospermum cream; Eucerin, Nivea with Calendula oil and Stellaria media; Glycyrrhetinic acid; Chamomile and Witch Hazel preparations; aloe vera (in mouth))
Pharmaceuticals (oral steroids)
Lichen planus triggers
viral, bacterial, stress, liver disease, inflammatory diet
mercury amalgam, copper, gold
ACE inhibitors, antiarthritic, antibiotic, antimalarial, antitubercular, chelators, color film developer, diuretic, hypoglycemic agents
Erythema Multiforme Syndrome pop
under 20, up to 40, male,
Erythema Multiforme Syndrome triggers
Sulfonamides, phenytoin, barbiturates, phenylbutazone, penicillin, allopurinol
Hep B vaccine
ACD-tattoos
Infection: Especially following herpes simplex, mycoplasma, EBV, cytomegalovirus
Idiopathic: more than 50%
Erythema Multiforme Syndrome sx
Dull red, Iris or targetlike lesions, macules to papules, localized or generalized, often symmetric
back of hands, palms, face, eyes
can be severe so they can’t swallow
Erythema Multiforme Syndrome TX
ID triggers and Tx
topical steroids or oral steroids for moderate-severe
Erythema nodosum sx
painful red swollen nodules on the extensor aspect of the extremities.
Prodrome: fever, malaise, later arthralgias, arthritis and hilar adenopathy
Erythema nodosum cause
Acute inflammatory/ immunologic rx of subcutaneous fat, bacterial, fungal, viral, drugs, malignancies, misc, and idiopathic(50%)
sore throat triggered
Erythema nodosum pop
female, any age, 18-34
Erythema nodosum DX
CBC-leukocytosis in most cases
Antistreptolysin-O titer
Chest x-ray
Consider tuberculin skin test
Erythema nodosum TX
ID and treat
elevating legs, compression dressings and wet bandages
potassium iodide
Oral steroids
Ecthyma
ulcerative impetigo
folliculitis
superficial hair follicle
furuncles
deeper hair follicle infection
Carbuncles
several adjoining follicles
