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CP113

Terms in this set (91)

Dermatology patient counseling - points to address
- Recent exposures
- Affected body areas
- Duration
- Nature of lesions (confined/diffuse? oozing?)
- Agents tried
- Family history
Pustule
Circumscribed, elevated lesion containing pus (commonly infected)
Papule
Solid raised lesion < 1 cm in diameter with distinct borders
Vesicle
Raised lesion < 1 cm in diameter filled with fluid
Bullae
Lesion > 1 cm in diameter filled with fluid
Crusting
Dried pus
Lichenification
Increased epidermal markings
Excoriations
Abrasion of the epidermis by trauma
Astringent
Causes hardening of intercellular cement of capillary epithelium and vasoconstriction of blood vessels to retard weeping, oozing, discharge and inflammation

Allows for "drying/cooling" of wet lesions
Keratolytic
Agent that allows for softening/shedding of outer layer of skin
Layers of skin (superficial to deep)
Epidermis (water regulation)

Dermis (40x thicker than epidermis, contains vasculature)

Hypodermis (adipose)
Atoptic dermatitis and dry skin (definition)
Inflammatory condition of epidermis/dermis

Characterized by episodic flares of intense pruritis and periods of remission

Cannot be cured
Atoptic dermatitis and dry skin (etiology)
Genetic

Deficient skin barrier causing increased penetration of allergens
Atoptic dermatitis and dry skin (pathophysiology)
Inflammatory cytokines
Atoptic dermatitis and dry skin (epidemiology)
Often begins within 1st year of life, remission by 2nd year

Dry skin continues into adulthood
Atoptic dermatitis and dry skin (clinical presentation - classification)
ACUTE =
Intensely pruritic, erythematous papules or vesicles over erythematous skin --> excoriation and pus

SUBACUTE =
Erythematous, excoriated papules and plaques that can be scaly

CHRONIC =
Thickened plaques and skin marking; often also has features of acute and subacute
Atoptic dermatitis and dry skin (clinical presentation - location)
CHILDREN =
Cheeks, face, neck, trunk

ADULTS =
Symmetric flexor surfaces (ie. back of knees)
Atopic dermatitis (diagnostic criteria)
Pruritic skin disorder, plus 3+ of the following criteria:

- Onset < 2 y/o
- History of skin crease involvement (including cheeks in children < 10 y/o)
- History of generally dry skin
- Personal history of other atopic disease (asthma, allergic rhinitis) or history of atopic disease in 1st degree relative (if child is < 4 y/o)
- Visible flexural dermatitis (or dermatitis of cheek/forehead and other outer limbs if child if < 4/yo
Dry skin (causes)
Generally, decreasing skin hydration

- Aging
- Long, hot showers (allows moisture to leave skin)
- Dehydration
- Environment (arid, windy, winter)
- Overexposure to sun
- Damage to stratum corneum
- Malnutrition
- Prolonged detergent use
- Certain jobs/swimmers
- Hypothydroidism
Atopic dermatitis and dry skin (goals of self-tx)
(1) Stop itch-scratch cycle

(2) Maintain skin hydration

(3) Avoid/minimize factors that trigger/aggravate disorder

(4) Prevent secondary infections
Atoptic dermatitis and dry skin (when to refer)
- slides say < 2 y/o (book says < 1 y/o)
- 2ndary cutaneous infections (yellowish crusting of lesions, pus-filled pustule/vesicle)
- Severe condition with intense pruritis
- Involvement of large area of body
- Failed 7 days of self-tx
- If lesions are present, refer if not dry after 2 days of self-tx
Atoptic dermatitis and dry skin (non-pharm tx)
- 3-5 min showers every other day, tepid water, moisturizer within 3 min after shower
- Use mild non-soap cleansers (eg. Cetaphil)
- Keep fingernails short
- Cotton gloves/socks at night
- Use humidifier
- Stay hydrated
- Minimize triggers (foods, aeroallergens, stress, air pollutants, cosmetics/fragrances, detergents/soaps, tight-fitting clothes)
Atoptic dermatitis and dry skin (OTC treatment)
GOAL = enhance hydration of dry/fissured skin

- Hydrocortisone 0.5 - 1% (ointment or cream)
- Moisturizers (creams/lotions)
- Emollients (ointments)
- Astringent (for oozing/weeping lesions)
- Colloidal oatmeal
- Humectants (if severe)
Moisturizers
- Eucerin
- Aveeno Eczema Therapy
- CeraVe

INDICATIONS =
- Atopic dermatitis
- Dry skin

Creams and lotions

Applied 3-4 times daily

MOA =
Water evaporates and leaves behind active agents (lipids and humectants that impart moisture to the skin)

(+) Cosmetically-acceptable (disappears after application)
(-) Requires more frequent applications
Emollients
- Aquaphor (41% petrolatum)
- Cetaphil
- AmLactin
- Lubriderm
- Neutrogena
- Lanolin

INDICATIONS =
- Atopic dermatitis
- Dry skin

Ointments (water in oil)

Applied 3-4 times daily

MOA =
Leave an oily film on skin surface that traps in moisture

(+) Maintains hydration best
(+) Best for thick or scaly skin
(-) Greasy
(-) Difficult to spread (especially if hairy)

C/I =
- Lesions (can lead to maceration and infection)
Cool (tap water) compresses
INDICATIONS =
- Oozing/weeping lesions
- Atopic dermatitis
- Dry skin

Apply for 5-20 min, 4-6 times daily
Burrow's solution
Aluminum acetate (5%), astringent

Compress, soak 15-20 min, 3-4 times daily

INDICATIONS =
- Oozing, weeping lesions
- Atopic dermatitis
- Dy skin

(-) Fresh solution for each application
Hydrocortisone
Cortizone 10 Creme, 1%, steroid

INDICATIONS =
- Atopic dermatitis
- Dry skin (if accompanied by pruritis)
- Seborrhea resistant to medicated shampoo

Apply sparingly to affected area(s) 1-2 times daily, max 7 day tx

MOA =
Suppresses cytokines to decrease inflammation/itching

C/I =
- Open, cracked or infected skin

(+) Most preferred
(+) Not greasy
(-) Use intermittently to avoid tachyphylaxis
(-) Do not cover lesions treated with hydrocortisone
Colloidal oatmeal
Aveeno soothing bath treatment

C/I =
- Elderly
- Fall risk

(+) Relieves itching
Humectants
- 5% glycerin
- Propylene glycol
- 20-30% urea (keratolytic; binds skin protein, keratin, to increase skin elasticity; can cause stinging, burning, irritation; avoid on broken skin); lactic acid (keratolytic)
- e.g. Nivea

INDICATIONS:
- Severe atopic dermatitis
- Severe dry skin

MOA =
Draws water into stratum corneum to hydrate skin (hygroscopic)
Antipruritics
- Non-rx topical anesthetics (pramoxine, lidocaine, benzocaine)
- Counterirritants (camphor, menthol)
- Topical/oral antihistamine (diphenhydramine)

INDICATIONS =
- Guidelines do not recommend use for atopic dermatitis or dry skin
Contact dermatitis (definition)
Inflammatory skin condition in response to allergic or irritant agents

Characterized by inflammation, redness, itching, burning, stinging on dermal areas of skin

Irritant contact dermatitis (ICD)
Allergic contact dermatitis (ACD)
Irritant contact dermatitis (etiology)
Irritant directly damages skin

- Urushiol (poison oak)
- Nickel
- Formaldehyde
- Cosmetics
- Latex
- Benzocaine
- Thimerosal
- Neomycin
Allergic contact dermatitis (etiology)
Allergen-induced immune response (type IV)

- Cleansers
- Rubbing alcohol
- Bleach
- Fiberglass
Allergic contact dermatitis (onset)
24-48 hrs if previously sensitized
Irritant contact dermatitis (onset)
Minutes to hours
Contact dermatitis (presentation)
- PRURITIS
- Erythema
- Stinging
- Swelling
Contact dermatitis (when to refer)
- < 2 y/o
- Failed 7 days self-tx or present > 2 weeks
- > 20% BSA
- Involvement of eyes, eyelids, genitalia
Allergic contact dermatitis (goals of tx)
(1) Remove and avoid further contact with offending agent

(2) Treat inflammation

(3) Relieve itching and excessive scratching that may lead to open lesions and potential secondary skin infections

(4) Relieve accumulation of debris that arises from oozing, crusting and scaling of vesicle fluids
Urushiol-induced allergic contact dermatitis (OTC prevention)
Barrier product = IvyBlock Lotion (Bentoquatam)

Apply 15 min before exposure; repeat q4h until potential exposure ended

Flush area with water to remove from skin

(-) Flammable!

Precaution:
- Children < 6 y/o
Urushiol-induced allergic contact dermatitis (non-pharm prevention)
- Wear clothing to cover exposed areas
- Remove all clothing worn during exposure
- Clip and clean under fingernails
- Thoroughly wash any shoes, gloves, jackets, etc.
- Cleanse fur of pets after known or suspected exposures
Urushiol-induced allergic contact dermatitis (non-pharm treatment)
Wash affected areas within 30 min of exposure:

- Reduces contact time with irritant
- Helps localize symptoms
Urushiol-induced allergic contact dermatitis (OTC treatment)
NON-WEEPING LESIONS =
- Topical hydrocortisone 1% cream or ointment (3-4 times daily)
- Calamine lotion (shake well, apply to affected areas
- Colloidal oatmeal bath (relieves itching)

WEEPING LESIONS =
- Burrow's solution (5% aluminum acetate, 2-4 times daily)
- Colloidal oatmeal bath
- Topical hydrocortisone 1% cream (3-4 times daily) - NO OINTMENTS FOR WEEPING LESIONS
- Cool water bath/compress
Scaly dermatitis (definition)
Accelerated hyperproliferative epidermal condition of chronic nature

- Dandruff
- Seborrhea
- Psoriasis
Dandruff (clinical presentation)
AGE OF ONSET =
Puberty or later

AFFECTED AREA =
Scalp

SURFACE AREA =
Diffuse

PRESENTATION =
White/grey flakes

PRURITIS =
Yes

INFLAMMATION =
No
Seborrhea (clinical presentation)
AGE OF ONSET =
Birth, puberty or later

AFFECTED AREA =
Scalp, face, trunk

SURFACE AREA =
Patches

PRESENTATION =
Yellow/oily lesions +/- redness

PRURITIS =
Yes

INFLAMMATION =
Yes
Psoriasis (clinical presentation)
AGE OF ONSET =
- Childhood (genetic)
- Late adulthood (not genetic)

AFFECTED AREA =
Elbows, knees, lumbar, back of ears

SURFACE AREA =
Patches

PRESENTATION =
- Silvery/red plaques
- Punctate bleeding points at sites of scale removal

PRURITIS =
Not common

INFLAMMATION =
Yes
Scaly dermatitis (when to refer)
- < 2 y/o
- Failed 2 weeks self-tx

ONLY FOR PSORIASIS =
- >5% BSA involvement
Dandruff (treatment)
1st LINE =
- Pyrithione zinc
- Selenium sulfide
- Ketoconazole shampoo

2nd LINE =
- Coal tar (may discolor light hair, clothing; limited efficacy)
- Keratolytic shampoo (salicylic acid or sulfur) (requires longer tx with limited efficacy)

REFER if no improvement after 1-2 weeks
Seborrhea (treatment)
1st LINE =
- Pyrithione zinc
- Ketoconazole shampoo

2nd LINE =
- Keratolytic shampoo (salicyclic acid or sulfur) (requires longer tx with limited efficacy)

IF ERYTHEMA PERSISTS AFTER MEDICATED SHAMPOO USE =
- Hydrocortisone ointment, 2 times daily, max 7 day tx

REFER if no improvement after 1-2 weeks
Psoriasis (treatment)
1st LINE =
- 1% hydrocortisone for acute, localized flares (bright red lesions)

TRIGGER REDUCTION =
- Physical, chemical or UV trauma
- Meds (beta-blockers, lithium, steroid withdrawal)
- Stress
- Obesity
- Alcohol
- Tobacco

REFER if no improvement or worsening after 2 weeks of self-tx
Pyrithione zinc
INDICATIONS =
- Dandruff (1st line)
- Seborrhea (1st line)

Medicated shampoo, 0.3 - 2%

MOA =
Non-specific toxicity to epidermal cells

S/E =
Reports of ICD when used on broken skin

(-) Slower-acting than selenium sulfide
Selenium sulfide
Head & Shoulders
Selsun Blue

INDICATION =
- Dandruff (1st line)

Medicated shampoo, 1%

MOA =
Anti-mitotic effect

S/E =
- Hair discoloration
- Residual odor
- May increase scalp oil

C/I =
- Broken skin (systemic toxicity)
Coal tar
INDICATION =
- Dandruff (2nd line)

0.5-5% medicated shampoo, cream, ointment, paste, lotion, bath oil, soap, gel

MOA =
Cross-links with DNA

S/E =
- Folliculitis
- May stain skin
- Irritant

*Note: In acute phase, use topical steroid first to decrease inflammation*
Salicylic acid
INDICATIONS =
- Dandruff (2nd line)
- Seborrhea (2nd line)
- Psoriasis (2nd line)

Soak affected area in warm water for 10-20 min, then apply keratolytic agent

MOA =
- Desquamation of hyperkeratotic epithelium which causes tissue to swell, soften, macerate, desquamate

Often combined with sulfur in OTC products

S/E =
- Altered hair appearance
- Irritated mucous membranes
- Conjunctiva

(-) May cause systemic toxicity
Ketoconazole
Nizoral

INDICATIONS =
- Dandruff (1st line)
- Seborrhea (1st line)

1% shampoo, antifungal

(1) Clean scalp w/ non-residue shampoo
(2) Massage shampoo into scalp and affected area of face
(3) Leave for 3-5 min
(4) Rinse 2-3 times
(5) Repeat twice weekly for 4 weeks, wait 3 days between treatments

MOA =
Acts against Malassezia yeast

S/E =
- Hair loss
- Skin irritation
- Abnormal skin texture
- Dry skin
Diaper dermatitis (etiology)
Over-hydration of skin d/t prolonged contact w/ urine, feces, friction
Diaper dermatitis (clinical presentation)
Progressive

Rash --> maceration --> papule formation --> vesicles/bullae --> oozing --> ulceration

Complication =
Secondary skin infection
Diaper dermatitis (when to refer)
CAN TREAT < 2 y/o!!!

- Present for > 7 days or failed 7 days self-tx
- Secondary skin infections
- Possible UTI
- Affected area outside of diaper region
- Oozing, blood, pus, vesicles, broken skin
- Frequent recurrences
Diaper dermatitis (non-pharm tx)
- Encourage frequent diaper changes

- Good cleaning hygiene

- Keep area dry

- Disposable diapers preferred
Diaper dermatitis (OTC tx)
1st LINE =
- Skin protectant
(Apply w/ each diaper change PRN up to 7 days; MOA = forms physical barrier between skin and irritant, lubricates, helps absorb moisture)

eg.
- Zinc oxide
- Calamine
- Petrolatum
- Lanolin
- Mineral oil

2nd LINE =
- Baby powder (corn starch v. talc)
(Do not use on broken skin - infection risk; keep away from baby's face to prevent inhalation)

In children < 2 y/o, no topical antifungals, antibiotics or steroids unless under MD supervision
Minor burns (definition)
1st degree =
- Epidermis only
- Red, non-blanching, non-blistering

2nd degree =
- Extends into dermis
- Drainage, pain, edema, erythema, skin tenderness

3rd degree =
- Tissue death occurs
- Dry, leathery area

*ONLY TREAT 1st DEGREE BURNS OTC*
Minor burns (when to refer)
- 2nd or 3rd degree burns
- >/= 2% BSA involvement
- Involvement of eyes, ears, hands, feet, perineum
- Chemical, electrical, inhalation burns
- Worsens after 24-28 hr of self-tx or not improving after 7 days of self-tx
- Advanced age
- Diabetes, multiple medical problems
- Immunocompromised host
Thermal burn
CAUSE =
Skin contact with hot objects or inhalation of smoke/vapors

TRIAGE =
Self care OK if 1st degree and < 2% BSA

TREATMENT =
Analgesics
Skin protectants

MONITORING =
Improvement within 24-48 hours or refer
Electrical burn
CAUSE =
Electrical energy produces heat and causes skin and tissue injury

REFER!
Chemical burn
CAUSE =
Skin contact with acids or alkalis

REFER!
Sunburn
CAUSE =
Acute overexposure of skin to UV radiation
Characterized by erythema (if severe ==> vesicles, bullae, edema, tenderness, pain)

TRIAGE =
Self-care

TREATMENT =
Analgesics
Skin protectants (avoid in 1st 24-48 hours)

MONITORING =
Healing within 3-6 days
Sunburn (when to refer)
- >15% BSA
- Dehydration
- Fever (> 101 F)
- Extreme pain persisting for > 48 hours
- Confusion, weakness or seizures
SPF
Sun Protection Factor

Extension in time to burn
(eg. if it takes someone 10 min to burn, SPF 6 will extend this to 1 hour; 10 min x SPF 6 = 60 min)
UVB causes burn

Higher SPF does NOT mean more UVA protection

Want broad-spectrum sunscreen
Sunscreen
Neutrogena
Coppertone
Bullfrog
Banana Boat

Active ingredients =
- Avobenzone (UVA) **most common
- Cinoxate (UVB)
- Ecamsule (UVA)
- Methyl anthranilate (UVB)
- Octyl methoxycinnamate (UVB)
- Octyl salicylate (UVB)
- Salisobene (short UVA)
- Oxybenzone (short UVA)

MOA (organic sunscreen) =
Absorbs energy, disperses energy in cyclical molecule --> until molecule used up!

(-) Frequent re-application
Sunburn (prevention)
MINIMIZE SUN EXPOSURE
- 4" brimmed hat
- UV sunglasses
- Long sleeves/pants
- Umbrella

SUNSCREEN (not sun"block")
- > SPF 15
- Broad-spectrum (UVA + UVB)
- Apply liberally 15 min pre-sun exposure and q30 min post-swimming, sweating, towel-drying
Phototoxicity
CAUSE =
Systemic medications and sun-exposed skin

REFER!
Photoallergy
CAUSE =
Topical meds and sun-exposed skin
Pruritic dermatitis

REFER!
Rule of 9
To determine BSA coverage

Front of head = 4.5%
Back of head = 4.5%
Trunk (front) = 18%
Trunk (back) = 18%
Each arm = 9%
Genitals = 1%
Each leg = 18%
Minor burns (counseling points)
Immerse affected area in cool tap water 10-30 min

ANALGESICS =
- Systemic: NSAID > APAP
- Topical: Benzocaine 5-20%, Lidocaine 0.5-4%

SKIN PROTECTANTS =
Allantoin, cocoa butter, petrolatum, shark liver oil, white petrolatum
- If burn is DRY ==> use skin-protectant ointment and/or absorbent dressing
- If burn is WET ==> soak area in cool tap water 3-6 times daily for 15-30 min THEN use skin-protectant ointment and/or absorbent dressing
Ceramide
INDICATIONS =
Atopic dermatitis
Dry skin

MOA =
Deposits lipids and fats
Sunblock
UVA + UVB

Zinc oxide
Titanium dioxide

MOA =
Reflect energy back out, prevent UV radiation from reaching skin
Asthma (definition)
CHRONIC disorder of the airways

Characterized by:
- Variable and recurring symptoms
- Airflow obstruction
- Bronchial hyper-responsiveness
- UNDERLYING INFLAMMATION
COPD (definition)
Characterized by:
- PERSISTENT airflow limitation
- Usually PROGRESSIVE
- Associated with enhanced chronic inflammatory response in airways to noxious particles/gases
Asthma (characteristic symptoms)
- Wheezing
- Cough
- Dyspnea

Symptoms worsen or occur with:
- Exercise
- Viral infection
- Exposure to tobacco smoke, animals, mold, pollen, chemicals/dust
- Changes in weather
COPD (characteristic symptoms)
CHRONIC and PROGRESSIVE:
- Wheezing
- Cough
- Dyspnea
- Excessive mucus/phlegm production
- Increased frequency of pneumonia and pulmonary infections
Asthma (age of onset)
Usually childhood, but can present at any age
Asthma (past history/family history)
Many patients have allergies and/or family history of asthma
Asthma (pattern of symptoms)
Varies (day to day, or over long periods)

Worsened by exposure triggers
Asthma (time course)
Often improves spontaneously or with treatment

Airflow limitation generally reversible but may become fixed
COPD (age of onset)
Usually > 40 y/o
COPD (past history/family history)
History of exposure to noxious particles/gases

Smoking or secondhand smoke exposure
COPD (pattern of symptoms)
Chronic, usually continuous

Worsened during exercise
COPD (time course)
Generally slowly progressive over years despite treatment

Airflow limitation GENERALLY NOT REVERSIBLE
Asthma (pathophysiology)
- Airway inflammation

- Airway hyper-responsiveness

- Intermittent airflow obstruction
COPD (pathophysiology)
- Airway inflammation

- Mucociliary dysfunction --> chronic mucus/phlegm

- Airway remodeling (structural changes such as fibrosis, alveolar wall destruction)
THIS SET IS OFTEN IN FOLDERS WITH...