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Flashcards in Dermatitis Deck (48)

What is contact dermatitis?

Inflammatory skin condition
Characterized by inflammation, redness, itching, burning, stinging, and vesicle and pustule formation on skin areas exposed


What are the subcategories of dermatitis?

Irritant contact dermatitis: occurs when the skin undergoes mechanical or chemical trauma on exposure to an irritating substance (around 80% of contact dermatitis cases)
Allergic contact dermatitis: occurs when skin is exposed to an allergen (required a primary exposure)


What are the types of reactions of contact dermatitis?

Acute reactions: red, edematous papillose in early phase, which become vesicles and bullae that ooze if the reaction is severe enough
Chronic reactions: primary lesions are minimal and secondary changes such as dryness, lichenification (toughening of the skin, giving a leather appearance), pigment changes, hyperkeratosis or thickening, excoriation and fissuring predominate
Itching is the primary symptom in both acute and chronic


What are the signs and symptoms of irritant contact dermatitis?

Mild irritants produce erythema, vesiculation and oozing while strong irritants produce blistering, erosions and ulcers


What are the signs and symptoms of allergic contact dermatitis?

Mild form similar to irritant exposure. A typical allergic reaction consists of grouped or linear tense vesicles and blisters.
Severe = edema, espeically in face and periorbital and genital areas


What are the types of irritants for contact dermatitis?

Plants (poison ivy, sunflowers, marigolds)
Foods (kiwis, bananas, peanuts)
Chemicals (fertilizers, weed killers)


What is poison ivy?

Consists of 3 leaflets
Edges may be smooth or toothed
Leaves vary in size (8-55 mm long)
Reddish in the spring
Green in the summer
Orange/red in autumn
The allergen is urushiol


What are risks/aggravating factors for contact dermatitis?

Gender (women are more frequently exposed due to cosmetic use)
Area on the body (different types of irritants; chrome, silver, gold, nickel jewellery)
Occupational (irritation through contact with chemicals; exposure of foods and plants)
UV light (phototoxic reactions when taking medications)


When should contact dermatitis be referred?

Dermatitis spreads to distant sites or becomes generalized to more than 30% of the BSA
Acute and non responsive with a few days
Edema persists or increases within a few days/swelling of the body or extremities/swollen eyes or eyelids swollen shut
Discomfort in genitalia from itching, redness, swelling or irritation
Involvement and/or itching of mucous membranes of the mouth, eyes, nose or anus
Chronic and non responsive within 7 to 10 days
Interferes with quality of
Child under 2 years of age
Presence of numerous bullae
Extreme or low tolerance to itching, irritation, or severe vesicle or bullae formation


What is atopic dermatitis?

Genetic based, chronic relapsing skin disorder
Usually begins in infants or early childhood and may last into adulthood
Most common dermatological condition in children
Exact cause is unknown
Aka eczema


Describe the pathophysiology of atopic dermatitis?

Chronic inflammatory skin disease associated with cutaneous and mucous membranes hyper-reactivity toward environmental triggers that are innocuous to normal, non-atopic individuals
80-85% have high levels of total IgE which leads to an eczema-type reaction
In infants, may be a prelude to the development of other atopic disorders later in life
Genetic impairment of epidermal barrier proposed cause of atopic dermatitis


What is "the triad"?

When someone has atopic dermatitis, allergic rhinitis and asthma


What are the signs and symptoms of atopic dermatitis?

Pruritus is the main symptom
No primary skin lesion
Skin is typically dry and lesions are scaly - though they may be vesicular, weeping and oozing in the acute stage
Pruritus may be focal or generalized. May be more intense in the evening and at night


What is the diagnostic criteria for atopic dermatitis (keep in mind that pharmacists cannot diagnose atopic dermatitis)?

Pruritus must be present, plus at least three of the following:
Onset before 2 years
History of skin crease involvement
History of generally dry skin
Personal history of other atopic disease (or history of any atopic disease in first degree relative in children over 4 years of age)
Visible flexural dermatitis (or dermatitis of cheeks/forehead and other out limbs in children over 4 years of age)


What are risk factors for atopic dermatitis?

Environmental allergens
Physiologic stress
Dietary influences
Itch-scratch cycle


When should atopic dermatitis be referred?

If dermatitis is acute or vesicular. Severe condition with intense pruritus
If moderate to severe defined as: large area of the body, remains unresponsive, skin appears to be infected (pus, fever, inflammation, warm), child under 2 years of age, interferes with activities of daily life or sleep patterns


How should dermatitis be assessed?

Signs and symptoms (atopic or contact dermatitis?)
Location and size of area (face, hands, flexural areas (elbows, knees) or area that was in contact with the irritant; covers large area of the body or specific smaller areas that were exposed to the irritants)
Risk or aggravating factors (family history, rapid temperature changes or sensitization to a specific irritant)
Appearance of lesions (red, raised blisters, dry thickened skin or red blisters, dry area)
What has been tried?
Past history?


Describe a patient assessment of dermatitis

Gather information: ask questions regarding the signs and symptoms (onset, progression, timeframe, locations and description of the lesions, presenting symptoms, and if previous occurrence)
Determine urgency: severity, area and extent of skin involvement; signs of a systemic/generalized reaction or condition
Medication history
Differential diagnosis


What are the goals of treatment of dermatitis?

Eliminate trigger factors or contact exposure to irritants and allergens
Provide symptomatic relief while decreasing skin lesions
Implement preventative measures focusing on decreasing the number of episodic flares, lengthening symptom-free periods and prevention of excoriations
Develop coping strategies the expectations for patients/caregivers


What are non-pharmacological treatment options for contact dermatitis?

Immediately wash with soap and water
Avoid or remove the allergen (tips on reducing exposure)
Take cold or tepid soapless showers
Avoid scrubbing affected area
Remove and wash all clothing exposed to irritant/allergen
Use wet compresses for acute weeping or oozing lesions


How should contact dermatitis be treated?

Identify and avoid irritants
Wet compresses for 20 minutes 4 to 6 times per day
Topical steroid may be used to treat symptoms on a short term basis. Acute symptoms should resolve with 7 to 10 days
In addition, an oral antihistamine may be added to therapy
Avoid topical anesthetics (cross sensitization) and topical antihistamines (contact sensitizers)


How should poison ivy be treated?

Shower after exposure (do not bathe)
Wash all items that have been exposed to the oil-shoes jewelry, tools and clothing
Wash clothing as soon as possible using oil free soap ("Sunlight" is a good example)
The initial rash can appear up to 9 days after exposure may appear within 1 to 2 days
To treat the itch and rash (application of a topical corticosteroid, oral antihistamine prn)


How can poison ivy be prevented?

Total avoidance to plant (easier said than done)
Wear protective clothing that can be removed if exposed to the oil/plant
Wash objects that have come into contact with the plant (use gloves to handle exposed objects)
Wash skin within 10 minutes of exposure
Do not burn the plant


What are the monitoring parameters for acute dermatitis?

Patient: Monitor daily while on drug therapy
Physician/pharmacist: after 7 to 10 days of therapy or next visit
Inflammation should reduce in 7-10 days
Surface area should not progress
There should be no extension to other sites or generalization
There should be no new blisters after 1 to 2 days
Itching and scratching should be reduced to tolerable level within 7 to 10 days
Sleep and daily activities should be restored to normal patterns within 2 to 3 weeks
Stress, anxiety and depression: re-establish normal pattern within 2 to 3 weeks


What are the monitoring parameters for chronic dermatitis?

Patient: monitor daily while on drug therapy
Pharmacist/physician: after 2 to 3 weeks or at next visit
Changes in inflammation, scaling, dryness, itch, scratching should be controlled by 4 to 8 weeks
There should be no progression in severity
There should be a lengthening of symptom-free periods throughout therapy


What are non-pharmacological treatment options of atopic dermatitis?

Bathing in lukewarm water for 5 minutes, every other day with tepid water, using mild non-soap cleansers
Pat skin dry
Trim nails short and smooth (keeps them clean)
Avoid occlusive, tight clothing. Wash new clothing.
Limit exposure to sudden temperature changes, maintain moderate humidity
Avoid triggers, allergens, and irritants
Use wet compresses for acute weeping or oozing lesions
Keep skin hydrated


How should atopic dermatitis be treated?

When skin is dry, mild itch or irritation, with no patches of dermatitis: emollient or barrier repair treatment recommended twice daily and after bathing
In an acute flare, topical corticosteroid or barrier repair therapy applied to the affected area. The skin lesion should resolve within 2 weeks. If effective, reinforce emollient use for prevention. If not effective, refer to physician


What are other prescription products for atopic dermatitis?

Topical calnieurin inhibitors - long term therapy for atopic:
Tacrolimus (Protopic)
Pimecrolimus (Elidel)


What does tacrolimus do?

Reduces itching and inflammation
Can be used on the face and neck
Can be used in children older than 2 years**


What does pimecrolimus do?

Causes less burning and itching than Protopic
Lower cost
Can be used in children older than 2 years**


What are OTC treatments for atopic dermatitis?

Skin protectants (calamine lotion, zinc oxide, colloidal oatmeal, sodium bicarbonate)
Oral antihistamines (act by blocking H1 receptors therefore decreasing itch caused by histamine (helpful for atopic dermatitis); first generation causes drowsiness; e.g., diphenhydramine 25-50 mg)
Moisturizers (emollients with humectants added - most efficacious; examples: Complex 15, Dermal Therapy, Lac-Hydrin)
Skin cleansers (Avoid soap in acute atopic or contact dermatitis; Cetaphil cleanser, Spectro-Jel, Tersaseptic)
Astringents (Aluminum acetate; can be used as a wet dressing, compress or soak; drying, soothing and mildly antiseptic; no evidence of superiority. Saline or tap water preferred)


What are some OTC products for atopic dermatitis?

Hydrocortisone cream (Cortate, Claritin)
Calamine lotion (various brands)
Zinc oxide (Zincofax, Ihles paste)
Colloidal oatmeal (Aveeno baths)
Sodium bicarbonate (Baking soda)
Aluminum acetate (Buro-sol)
Diphenhydramine (Benadryl)


What are the four "R"s of management of atopic dermatitis?

Recognize (diagnose condition and seek treatment early)
Remove (triggers)
Restore (moisturizers/ointments)
Regulate (treatment (OTC and Rx), follow-up)


What is diaper dermatitis?

The most common skin disorder in infants


Describe the pathophysiology of diaper dermatitis?

A form of contact dermatitis due to disruption of normal skin barrier (due to skin's contact with moisture, friction, urine and feces)
May be irritant, allergic or fungal


What are the signs and symptoms of diaper dermatitis?

Irritant: shiny red patches in the diaper area, fold of the skin are not affected
Candida Fungal Infection: presents with beefy red rash, papillose and pustules in the area; tomato red plaques, pustules; almost always seen in fold of skin


What are the risk factors for diaper dermatitis?

Irritants and friction: bowel frequency, excessive rubbing and over-cleaning
Comorbid conditions: atopic dermatitis
Type of diaper used (cloth poses higher risk than disposable diaper)
Occlusion and humidity


What should be considered during an assessment of diaper dermatitis?

Duration of symptoms
Area involved
Aggravating factors
Appearance of lesions
How often the diaper has been changed
Change in diet
Bowel movements
Any other skin conditions


What should diaper dermatitis be referred?

Lack of improvement after 7 days of treatment
Dermatitis extends outside the diaper area
Pain, itching or inflammation increases
Oozing blisters or pus present
Area shows signs of infection or another infection is present
Fever, nausea, diarrhea, rash elsewhere
Behavioural changes
Acute onset
Systemic symptoms
Signs of deficient immune system, deep ulceration, abuse to neglect
Co-existing skin conditions


What are the goals of therapy for diaper dermatitis?

Relief of symptoms
Resolution of dermatitis
Prevention of complications and recurrences


What are non-pharmacological treatment options for diaper dermatitis?

Bath daily - lukewarm bath
Use fragrant-free soap
Dry diaper area by patting gently
Baby wipes
Apply barrier product to diaper area
Diaper changes
Do NOT use powders such as talc and topical cornstarch


Describe barrier product use for the treatment of diaper dermatitis

Pastes are desirable as barriers
Pastes contain >10% zinc oxide, titanium dioxide, starch or talc
There are two categories: water impermeable and barrier/water-absorptive
Avoid products containing fragrances, preservatives, boric acid, camphor, phenol


What are water impermeable products?

Petrolatum (no capacity to absorb moisture, may cause maceration if applied to over hydrated skin)
Dimethicone or dimethylpolysiloxane (silicone based, water-repellant only, soothe by protecting against irritants)
Anhydrous lanolin or anhydrous eucerin (wool fat derivatives, potential contact allergens, not a first choice)


What is zinc oxide?

Mild antiseptic and astringent
Absorption increases with concentration (at lower concentrations (15%), use for prevention, at higher concentration (>25%), effective treatment)
A plain zine oxide barrier preferred


What are some barrier products available?

Aveeno Diaper Rash cream (zinc oxide 13%)
Desitin Ointment (zinc oxide 37%, cod liver oil)
Penaten Cream (zinc oxide 18%)
Vaseline (petroleum jelly)
Zincofax Ointment (various strengths of zinc oxide)
Barrier Cream (dimethylpolysiloxane 20%)


Besides barrier products, what are some OTC treatment options for diaper dermatitis?

Anti-fungal agents:
Clotrimazole 1% (Canesten)
Nystatin (Nyaderm)
Miconazole 2% (Micatin)


When should anti-fungal treatment be considered? Describe anti-fungal treatment

Seen in moderate to severe cases
Apply first and then apply the barrier cream
Apply twice daily for 1 week - stop when clear (if over 7 days, refer)
Nystatin is the least effective


Can topical corticosteroids be used for the treatment of diaper dermatitis?

Only under the supervision of a physician for children under 2 years old (topical hydrocortisone 0.5%)
Used in cases where allergic contact dermatitis is expected
Apply steroid first if being used with anti-fungal