Self Care Exam 3- Atopic Dermatitis, Dry Skin and Scaly Dermatoses

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Skin Function

~Protection from injury
~Barrier against microorganisms
~synthesis of melanin
~sensory input recipient
~vitamin D3 production
~prominent role in thermoregulation

Three layers of skin

~epidermis
~dermis
~hypodermis

Principles of drug absorption

~topical application
~passive diffusion
~percutaneous absorption
~general circulation

Drying agents

solutions, gels and occasionally creams

Lubricating agents

creams, lotions, ointments

crust

*secondary
*dried exudate containing proteinaceous and cellular debris from erosion or ulceration of primary lesion

erythema

*primary
*reddened skin

fissure

*secondary
*a split in the epidermis extending into the dermis

lichenification

*secondary
*thickening and hardening of the skin into irregular plaque due to excessive rubbing or scratching

macule

*primary
*flat, nonpalpable, discolored lesion less than 1cm in diameter; lesions larger than 1 cm are termed patches

necrosis

*secondary
*dead cells or groups of cells caused by severe trauma or an infectious process

papule

*primary
*a solid, circumscribed, elevatedlesion less than 1 cm in diameter

plaque

*primary
*a palpable, papular, relatively flat lesion more than 1 cm in diameter

pustule

*primary
*a circumscribed elevated lesion less than 1 cm in diameter containing pus; a larger lesion is termed an abcess or furnucle

scale

*secondary
*accumulation of loose, desquamated, hyperkeratitic epidermal cells

ulcer

*secondary
*an erosion of the epidermis exposing the dermis; deep ulcers may result in the destruction of the dermis

vesicle

*primary
*a sharply circumscribed, elevated lesion containing fluid; diameter may be up to 1 cm; if greater, then termed blister or bulla

other names of atopic dermatitis

eczema
atopic eczema
eczematous dermatitis

description of atopic dermatitis

chronic, relapsing skin disorder
exaggerated skin response to environmental stimuli
genetic basis, family history

Onset of atopic dermatitis

infancy or during early childhood

DIagnostic criteria of atopic dermatitis

Itchy skin, plus 3 or more of the following:
*Onset before 2 years of age
*History of skin crease involvement
*History of dry skin
*History of other atopic disease (or in 1st degree relative when <4 years old)
*Visible dermatitis on cheeks, forehead, and outer limbs

Exclusions for self treatment of atopic dermatitis

*severe condition with intense pruritus
*involvement of large body area
*<2 years of age
*signs/symptoms of bacterial or viral skin infection: pustules, vesicles, yellowish crusting

What are the goals of therapy of atopic dermatitis

*stop the itch-scratch cycle
*avoid/minimize aggravating factors
*hydrate skin
*prevent secondary infections

What are non-pharm measures for treating atopic dermatitis?

*wear irritant-free products
*loose clothing
*short fingernails
*moderate temperature
*bathing
*moisturizing

What is the patient education of atopic dermatitis?

*Avoid long, hot showers
*Use mild non-soap cleansers
*Moisturizer application
*Use liquid laundry detergent
*Keep fingernails short
*Avoid sudden and extreme temperature/humidity changes

Another name for dry skin

xerosis

Description of dry skin

abnormal loss of cells from the stratum corneum as a result of decreased water content in the skin
generally seen in older adults or people living in cooler climates during the winter

What is the etiology of dry skin

*disruption of keratinization and impairment of water-binding properties
*secondary to prolonged detergent use or physical damage to the stratum corneum
*sign of systemic disease

What is the clinical presentation of dry skin

*roughness
*scaling
*loss of flexibility
*fissures
*inflammation
*pruritus

What are the goals of therapy for dry skin

*restore skin hydration
*restore the skin's barrier function
*educate the patient about condition

Non-pharm therapy of dry skin

*oil or oatmeal bath
*use of oil-based emollients when skin is damp
*humidifier or vaporizer
*drink 8 ounce glasses of water daily

What is the patient education of dry skin

*avoid excessive bathing
*drink plenty of water
*apply moisturizers 3-4 times daily
*moisturizers should be applied within 3 minutes of bathing
*avoid caffeine, spices and alcohol
*keep the room humidity higher than normal

Types of moisturizers

*occlusives
*humectants
*emollients

Occlusives

coat the stratum corneum and decrease evaporation of water from skin

Humectants

glycerin, hyaluronic acid, propylene glycol
draw water into the stratum corneum from the dermis

Emollients

fill in the spaces between desquamating skin scales to create smooth surfaces

What is in a moisturizer

water (60-80%
lipids
emulsifiers
humectants
preservatives
fragrance
color
special additives

MOA of Urea (10-30%)

mildly keratolytic, increases water uptake in the stratum corneum
high water-binding
side effects: stinging, burning and irritation

MOA of lactic acid (2-5%)

increases skin hydration, may act as a modulator of epidermal keratinization

MOA of hydrocortisone (0.5-1%)

low-potency corticosteroid with mild anti-inflammatory effect

Side effects of hydrocortisone

epidermal atrophy, folliculitis

How long can you use hydrocortisone

up to 7 days

Application of cream/ointment (g) and lotion/solution/gel (mL) on various body parts

Face: 5-10g, 100-120mL
Both Hands: 25-50g, 200-240mL
Scalp: 50-100g, 200-240mL
Both arms or both legs:100-200g, 240-360mL
Trunk: 200g, 360-480mL
Groin & Genitalia: 15-25g, 120-180mL

3 types of scaly dermatoses

Dandruff
seborrheic dermatitis
psoriasis

Dandruff- cell turnover rate

13-15 days

dandruff- Signs and symptoms

large white or gray scales on scalp, pruritis

dandruff- goals of therapy

1. Reduce the epidermal turnover rate of the scalp skin
2. minimize cosmetic embarrassment
3. minimize itch

seborrheic dermatitis- Cell turnover rate

9-10 days

seborrheic dermititis- goals of therapy

1. reduce inflammation and the epidermal turnover rate of the scalp skin
2. minimize or eliminate visible erythema and scaling

Psoriasis- cell turnover rate

4 days

Psoriasis- signs and symptoms

Plaque, guttate, pustular or erythrodermic in nature, inflammation, minimal itching

Psoriasis- goals of therapy

1. control or eliminate the signs and symptoms
2. prevent or minimize the likelihood of flares

Exclusion criteria of scaly dermatoses

patients <2 yrs of age
no improvement after 2 weeks of self-care therapy
Psoriasis= BSA>10%

Goals of therapy for scaly dermatoses

*reduce epidermal turnover rate
*minimize the cosmetic embarrassment of visible erythema and/or scaling
*minimize itch
*prevent or minimize the likelihood of flares

Treatment options for scaly dermatoses

*cytostatic agents
*kerotolytic agents
*topical hydrocortison
*antifungals

MOA of cytostatic agents

decrease rate of epidermal cell replication

Adverse effects of cytostatic agents

skin irritation, staining (coal tar)

Active ingredients in cytostatic agents

pyrithione zinc
selenium sulfide
coal tar

MOA of keratolytic agents

loosen and lyse keratin aggregates, dissolving the bond that holds epidermal cells together

Adverse effects of keratolytic agents

skin irritation, alter hair appearance

Active ingredients of keratolytic agents

salicylic acid
sulfur

MOA of hydrocortisone

anti-inflammatory, antipuritic, vasoconstrictive and immunosuppressive on cellular activity

Adverse effects of hydrocortisone

atrophy, systemic sequelae

Active ingredients of hydrocortisone

hydrocortisone 0.5%-1%

MOA of ketoconazole

synthetic azole antifungal agent, active against pityrosporon yeast

Adverse events of ketoconazole

hair loss, skin irritation, abnormal hair texture, dry skin

Treatment options for dandruff

Pyrithione zinc
Selenium sulfide
Coal tar
Ketoconazole

Treatment options for seborrhea

Ketoconazole
Pyrithione zinc
Selenium sulfide

Treatment options for psoriasis

Hydrocortisone
Mild Cleansers
Emollients

Patient education of scaly dermatoses

Shampoo
*3 times/week initially
*leave on 3-5 minutes
*use minimum of 2 weeks
*weekly/bi-weekly for control
Cream
*apply thin layer
*2-3 times/day
Follow up
*consult PCP if no improvement after 1-2 weeks

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