Dermatitis
non-specific term
Generally characterized by erythema & inflammation
Skin may blister / ooze / crust / flake
Known causes:
Allergens / Irritants / Infections
Usually SELF TREATED
Atopic Dermatitis
AD
Primarily driven by GENETIC FACTORS
Usually develops in infantry, all over the body
especially in skin folds
Physical Contact with irritant / allergen may exacerbate
Contact Dermatitis
Driven mainly by EXTERNAL FACTORS
Develips @ site of physical contact w/ irritant or allergen
What is the “Atopid Triad”
or Atopic March
AD + Asthma + Allergic Rhinitis
Atopy = exaggerated skin & mucosal reactivity
in response to environmental stimuli
genetically predipsosed
Pathophysiology of AD
Skin is inflammed with and expression of CYTOKINES
IL-4, IL13, TNF
FLG = Fliggrin Mutation, INCREASES risk of AD
Diagnostic Criteria for AD
Essential Features:
Pruritis / Eczema
Important Features:
Early Age of Onset
Atopy / Xerosis / FMH
Possible Lab Findings:
Elevated IgE levels & peripheral blood eosinophilia
Characteristics of Atopic Dermatitis by AGE
3 Stages of AD
ACUTE AD
INTENSELY Pruritic + Papules/vesicles over erythematous skin
often associated with an exudate, pus/leak
- *SUB-ACUTE AD**
- *Red** / scaling papules / plaques
Chronic AD
Thickened plaques of skin
accentuated skin markings
Complications of AD
S/Sx = Pustules / Vesicles / Yellow Crusting
Secondary BACTERIAL infections
>90% of skin lesions harbor staph
Secondary VIRAL infections
Herpes simples or molluscum
Exacerbating Factors of AD
Allergens
Irritants
Temperature Changes
Airborn Irritants
Pollution / Cigarette Smoke / Traffic Exhaust
Goals of Therapy for AD
*CAN NOT be cured; symptom control is key
Stop Itch-scratch cycle
Topical steroids
Maintain skin hydration + barrier function
Emollients + Moisturizers
Avoid or Minimize exacerbating factors
prevent 2ndary infections
Bathing Procedures for AD
Bathe in lukewarm water for limited duration
Fragrance-Free bath oils (Aveeno)
Use hypoallergenic cleanser (Cetaphil)
Skin should be patted dry or air-dried
Application of moisturizer within 3 minutes of bathing
Use lubricating ointment for excessively dry areas
What type of moisturizers for LESS severe cases?
Atopic Dermatitis treatments
EMOLLIENTS
Aquaphor / Nivea
What type of moisturizers are used for MORE SEVERE cases?
Atopic Dermatitis treatments
- *HUMECTANTS**
- *Eucerin + Urea**
UREA increases water uptake in the stratum corneum
giving it high-water binding
RX Strength Urea acts as a KERATOLYTIC agent
Creams
Atopic Dermatitis treatments
Usually Oil-in-Water emulsions (O/W)
LESS occlusive than ointments
common mistake = using too much and/or not rubbing in fully
Cetaphil / Nivea
Ointments
Atopic Dermatitis treatments
W/O emulsions
Act primarily by leavan an oily film on the skin surface
that moisture can NOT readily escape
MOST OCCLUSIVE vehicle
relives dryness / brittleness / protects fissures
- AVOID ON*:
- Inflammed skin / interinous areas / hairy areas*
WEEPING LESIONS
Topical Steroids
Dose / MoA / ADR
Atopic Dermatitis treatments
- *STANDARD OF CARE**
- *Hydrocortisone** 0.5% & 1%
- low potency*
MOA: Supresses cytokines associated with the development of inflammation and itching
minimal systemic absorption (~1%)
During flare ups: AAA BID
prior to application of moisturizers
AVOID use if skin is infected / open / cracked
Wet Wraps
AD Treaments
INCREASES Skin Hydration
decreases _scratching_
Apply steroid or emollient to affected area
then wrap MOIST dressing to AA
then wrap a DRY dressing OVER the wet one
put over nighttime clothing -> LEAVE WRAP OVER NIGHT
Astringents
Atopic Dermatitis treatments
Aluminum Acetate & Witch Hazel
Cause vasoCONSTRICTIOn & reduce Bloodflow to inflammed tissue
slow oozing / discharge / bleeding
- *Wet Dressing**
- *Cool & dry** skin through EVAPORATION
(Burrows solution / Domeboro)
Burow’s Solution
Directions / Duration
Type of Atopic Dermatitis treatments
Category 1 ASTRINGENT
Dissolve 1-3 packets in a PINT (16oz) of cool/warm water -> dissolve
for use as SOAK:
soak AA for 15-30 min Q8H PRN, or AD by a doctor
for use as COMPRESS or WET DRESSING:
soak a clean/soft cloth in the solution
apply cloth looselyto the AA for15-30 min, reapply PRN
How to PREVENT / MANAGE Infections
Atopic Dermatitis treatments
Topical Antibiotics NOT routinely recommended
- *Bleach Bath_ & _IntraNASAL MUPIROCIN**
- BID** used to *_decrease disease severity_
Bleach bath for ECZEMA:
1/2 cup for a FULL TUB or 1/4 cup for HALF tub
soak for 10 minutes -> Dry -> Lotion -> WRAP w/ eczema clothing
EX-ST
for ATOPIC DERMATITIS
SEVERE condition with INTENSE PRURITIS
Involvement of LARGE AREA of the body
< 2 years old
Skin appears to be INFECTED
No improvement after 2-3 days of self care
Important notes on AD
Most AD cases are MILD and can be treated with NON-RX products
for patients >2 y/o
Need to be counseled on potential exacerbating factors
Errors in BATHING / Moisturizing procedures are THE MOST COMMON FACTORS in persistant AD
Treatment should involve focus on skin care / moisturization in order to enhance/restore barrier properties
OTC therapies can be recommended for symptomatic treatment of dermatosies to reduce inflammation / pruritis
What Characterizes CONTACT DERMATITIS?
Inflammation / Redness / Itching / Burning / Stinging
- *VESICLE + PUSTULE** formation on dermal areas that are
- *Exposed to irritant / antigenic agents**
2 Main types:
Irritant & Allergic
What are the 3 possible mechanisms that cause
Irritant Contact Dermatitis?
ICD
Caused by exposure to an irritant:
DISRUPTION of skin barrier
Irritant may DIRECTLY DAMAGE the epidermis
Release of CYTOKINES as a result of chemical exposure
Common IRRITANTS associated with ICD
Acids / Alkalis
Detergents / soaps / hand sanitizers
Oxidants / Solvents
Urine / Feces
Epoxy Resins / Ethylene Oxide / Oils
Wood dust / products
Symptoms / Clinical Presentation
of ICD
Skin becomes inflammed / swollen / red on exposure to IRRITANTS
symptoms may be DELAYED, often limited to hands & forearms
Presents as DRY / MACERATED / PAINFUL / CRACKED skin
that often induces:
Itching / stinging / burning
Generally resolves within a few days, if AVOIDING irritant
CHRONIC EXPOSURE
-> develop FISSURES / SCALES / Pigmentation
3 Treatment goals of ICD
- *REMOVE / PREVENT**
- *exposure** to the irritant
RELIEVE
inflammation / tenderness / irritation
EDUCATE
patient on self-management to PREVENT recurrence
What to AVOID in treating ICD
AVOID:
topical CAINE-type anesthetics
Salicylic / Lactic ACID
UREA
PROPYLENE GLYCOL
TREATMENTS for ICD
Cleansing
area of exposure with tepid water & hypoAllergenic soap (Cetaphil)
Protective** **clothing / equipment
to avoid further exposure
Emollients / Moisturizers
to assist in REPAIRING epidermal barrier
Corticosteroids
to reduce _inflammation_ & relieve itching
- *Colloidal OATMEAL Bath**
- also to relieve ITCHING*
What is Allergic Contact Dermatitis = ACD?
and what are common allergens?
Inflammatory dermal RXN related to exposure to allergen
Activites sensitized T-Cells
Usually does NOT appear on first contact
Poison ivy/oak/sumac = MOST COMMON CAUSE
Metal Allergy (NICKEL)
LATEX
STEPS to developing ACD
- *Induction phase**
- *INITIAL exposure** to antigen –> sensitizes the immune system
Next Contact
induces type 4 IV delayed hypersensitivity reaction
cell mediated IMMUNE rxn –> 24hours - 21 days to develop
Dermatitis
along with associated symptoms
if _previously sensistized_,
may appear between 24-48hours after exposure
Urushiol-Induced ACD
Caused by Toxicodendron species = Poison IVY
can occur in a BROADER AREA
80% of people are sensitive to it & it INCREASES into adulthood
declining sensitivity with _advanced age_
but with prolonged duration & severity of symptoms
Symptoms / CLinical Presentation of ACD
Can ocur ANYWHERE on the body after contact with antigen
- *Rash is limited** to the area of antigen contact
- Urushiol-induced ACD* can occur on BROADER area
Presents w/:
Papules / Small vesicles / Large Bullae
over inflammed / swollen skin
SIGNIFICANT ITCHING
Heals in 10-21 days as a result of our own immune system
Treatment Goals of ACD
REMOVE offending agent
TREAT inflammation
RELIEVE itching & excessive scratching
Relieve accumulation of debris
PREVENT secondary skin infection
What to AVOID when treating ACD
use of TOPICAL:
Anesthetics
Antihistamines
Antibiotics
known SENSITIZERS
–> can cause drug-induced ACD
superimposed on the existing AC
Treatments for ACD
REMOVE the known antigen
w/ mild soap & tepid water + Zanfel / Tecnu for Urushiol
Rash w/ pruritis & erythema
treat with Hydrocortisone 1% , CREAM>ointment for WEEPING lesions
Oozing Vesicles
use Astringents or cool water compress to DRY
- *Non-Weeping_ _Lesions**
- *Calamine Lotion** -> Drying / Colloidal Oatmeal –> Itching
TECNU
ACD Treatments
Skin cleanser used to REMOVE KNOWN ANTIGEN
for URUSHIOL-induced ACD
use ASAP up to <8 hours after exposure
- *Cleanse** the contaminated area for >2minutes
- *Wipe away** with cloth or rinse with water
EQUAL efficacy between
Tecnu / dish soap / GOOP grease remover
Zanfel
ACD Treatments
Skin cleanser used to REMOVE KNOWN ANTIGEN
for URUSHIOL-induced ACD
Can be used at any time following exposure, even after rash develops
because it provides RELIEF from PAIN & ITCHING
MoA:
bonds with urushiol within the dermal layer to create an aggregate that can be washed away w/ water
Ivy Block
ACD Treatment
Lotion that is the only FDA approved
BARRIER PRODUCT
provides protection against exposure to:
poison ivy / oak / sumac
BENTOQUATAM
active ingredient believed to physically block urushiol from being absorbed into the skin when applied
<15 minutes PRIOR to exposure
REAPPLY once Q4HOURS
EX-ST / Refer to MD
for ACD
Children <2 years old
Involvement of Eyes / eyelids / mouth / genitals
or >20% of skin surface
Rash does not improve in 1-2 weeks
or failure of Self management _>7 days_
S/Sx of INFECTION
Presence of numerous LARGE Bullae
SWELLING of body / impairment of daily activities
Important Patient counseling for ACD
Bathing Procedure
AVOID triggers/allergens
Humidifyer + adequate HYDRATIOn
Minimize SCRATCHING
fingernail hygiene
Correct use of moisturizers + OTC products
Important notes on CONTACT DERMATITIS
ICD / ACD
should resolve within 10-21 days W or W/O therapy
knowing the surrounding circumstances for the occurance helps
leading cause of ICD = frequent / unprotected exposure
to WET environments that may contain irritant
ACD is produced through sensitization to antigen
Discuss preventative therapies
Washing (remove) > Hydrocortisone (itching) > Astringents (weeping/oozing lesions) > Emollients (restore barrier)
Zanfel INSTRUCTIONS for use
- Wet affected area
- Measure 1 ½ inches of the product into one palm
- Wet both hands and rub the product into a paste
- Rub both hands on the affected area until there is no sign of itching (up to 3 minutes)
- Rinse the affected area thoroughly
- If itching returns after several hours, the product may be used again
Inflammation
How to treat this SYMPTOM in ACD?
HYDROCORTISONE
Most effective NON-RX therapy
for mild-moderate ACD, that does NOT involve edema/extensive areas
Urushiol ACD may require RX-strength corticosteroid
AAA TID-> QID
_DO NOT USE DRESSINGS / BANDAGES_
when self-care
ITCHING
How to treat this SYMPTOM in ACD?
Cold or tepid soapless SHOWERS
or use hypoallergenic soap (cetaphil)
you can use oral antihistamines, not topical
Topical hydrocortisone
will help the itching through vasoconstriction
Oozing Lesions
How to treat this SYMPTOM in ACD?
- *ASTRINGENTS**
- *Aluminum Acetate = Burow’s Solution**
used as a wet dressing or compress
applied to unhealthy skin to
decrease:
weeping / oozing / discharge / bleeding