Xerosis and Dermatitis 2 Flashcards
Questions to Assess Patient
Symptoms: Itch? Pain? Burning? Lack of sleep? Any systemic symptoms?
Characteristics: Can you describe the dermatitis? Oozing? Erythema? Fissures? Hypo or hyper pigmentation? Scaling? Thickening of skin? Signs and symptoms of infection?
History: How long? Does it come and go? Have you experienced this before? History of atopy? History of edema in lower limbs?
Onset: When did it start? What were you doing? Anything change in your life at that point?
Location: Where is it?
Aggravating Factors: What make it worse? Probe with specific examples.
Remitting Factors: What makes it better? Probe with specific examples.
Explanatory Model: How does this symptom or condition affect you?
Red Flags
- Concomitant skin infection
- Large body surface area is involved, open wounds that are oozing or blistering
- Systemic symptoms present (fever, malaise, pain)
- Patient is psychologically distressed and requires an assessment
- Patient needs a prescription drug product?
- Assess you competency as a prescriber
- Patient is experiencing side effects from prescribed treatment
- Treatment failure (after you assess adherence)
- Ambiguity on diagnosis
- Pharmacists need to be astute in considering differential diagnoses of skin conditions
Goal of Therapy (4)
Incorporate patient’s goals as well as clinically
suggested goals
Suggestion of goals:
- Restore barrier function
- Provide symptomatic relief while decreasing skin lesions
- Implement proactive measures focusing on preventing or decreasing the number of flares or exacerbations
- Increase symptom free periods and empower patient/caregiver with strategies to manage skin condition
- Decrease impact on quality of life and psychosocial distress
due to condition
General Principles of a Care Plan for Xerosis and Dermatitis (3)
Combination of multiple non-pharmacological interventions (patient education) and +/- pharmacological agents (moisturizers +/- nonprescription drugs +/- prescription
drugs)
General principles for xerosis and dermatitis
1. Avoid aggravating/contributing factors and eliminate cause as applicable
2. Implement lifestyle measures
3. Add pharmacological treatment, first with moisturizers for uncomplicated cases to help restore barrier function and then add prescription products as needed
First step details for care plan - 1. Address Contributing Factors
Can these factors be addressed:
• Hypothyroidism,
initiate thyroid hormone supplement
• Keep skin covered to avoid weather elements (wind, extreme heat)
• Can irritating or drying skin products be discontinued?
First step details for care plan - 2. Self-care Measures
• Avoid excessive bathing or long baths or showers; use tepid water
• Increase humidity indoors
• Cool mist humidifiers preferred
• Humidity should be between 40% and 50%
in winter (30% in summer)
• Avoid wool clothing that may be irritating to the skin
• Cotton clothing next to the skin is less irritating
• Avoid swimming in chlorinated pools (Practical?)
• Avoid products that contain ingredients that may
sensitize the skin
• Maintain good nutrition and adequate fluid intake
from food and water
• Stress management
First step details for care plan - 3. Moisturizer & Principles
- Choose noncomedogenic, nonirritant and hypoallergenic moisturizers
- Helps to restore the barrier capability of the epidermis and decrease TEWL
- Patients will have to use on an ongoing basis
- Apply the moisturizer after bathing while skin is damp
- Apply several times a day (3–4 times daily)
- If using a bath product to moisturize, add bath products at the end of a bath or after a bath
- Replace standard soap with a substitute such as a synthetic detergent cleansers
Moisturizer: Occlusive agents - MOA? Examples? Notes?
Form a layer on the skin that inhibits moisture evaporation. Used in conjunction with hydration.
Examples: mineral oil, dimethicone, petrolatum
Additional notes:
- These agent are not appealing on the face
- In very hot and humid climates, can be overly greasy and occlusive
Moisturizer: Humectants - MOA? Examples? Notes?
Hygroscopic, attract water to the skin
Examples: Alpha-hydroxy acid (AHA) (glycolic acid,
lactic acid), glycerin, propylene glycol, urea
Additional notes:
- Formulations may sting if used on open wounds. People with sensitive skin may not tolerate.
- Use with an occlusive agent. Lactic acid (>12%) and urea (>10%) are keratolytic and their use is reserved for
treatment of more severe skin conditions with thick scales
Moisturizer: Emollients - MOA? Examples? Notes?
Fill in the spaces between stratum corneum, sealing moisture in the skin. Lubricate stratum corneum and slow evaporation. Most are oil in water or water in oil emulsions (the more oil, the less evaporation due to increased occlusion).
Examples: colloidal oatmeal, glycol, glyceryl stearate, shea butter and soy sterols
Additional notes:
- Choose an emollient for its drying or lubricating properties as suitable for the stage of dermatitis.
Misc Products: Bath products- MOA? Examples? Notes?
Provide a layer of oil on the skin that prevents moisture
evaporation
Examples: colloidal oatmeal, liquid paraffin
Additional notes:
- Best applied at the end of the bath or shower or
immediately after using a wet compress. Safety hazard if added to bath water (increased chance of slipping).
Colloidal oatmeal relieves itching and enhances the barrier function of the skin. Avoid fragranced bath salts and bubble baths.
Misc Products: Barrier Repair Products - MOA? Examples? Notes?
Normalize skin barrier by replacing lipids; decreasing
transepidermal water loss (TEWL); decreasing response to triggers for inflammation.
Example: Ceramides/cholesterol/free fatty acids
combinations, filaggrin, silicone and/or zinc related
compounds
Additional notes:
- Need to apply liberally
Topical Corticosteroids - what is it? formulation types?
Reduce inflammation and pruritus, useful for acute flare and chronic presentation
Various potencies:
- Potency depends on: chemical structure of the steroid molecule, concentration, and formulation/vehicle
- Low potency recommended for thinner skin, higher potency for thicker skin
Various formulations (gel, lotion, cream, solution, ointment, spray, foams)
- In general ointments are considered more potent, more occlusive, contain less preservatives. Creams are suggested in excessive heat or humid environments. Sprays, foams and solutions are good for hair bearing
areas.
- The formulation type can cause potency differences of two or three classes between preparations with the same corticosteroid molecule!
Topical Corticosteroids - site absorption
Relative absorption: Forearm -1 Sole-0.14 Back-1.7 Scalp-3.5 Forehead-6.0 Cheek-13.0 Scrotum-42.0
Topical Corticosteroids - Counselling tips
Apply a thin layer to affected area as prescribed (usually qd or bid).
- Suggest finger tip unit
Use in conjunction with a moisturizer = greater efficacy of steroid.
If patient using continually (daily), suggest 3 weeks “on” and 1 week “off” approach to mitigate tachyphylaxsis to TCS and minimize side effects.
To maintain remission, patient may use TCS twice weekly with moisturizer being used daily.