Dermatitis and Eczematous Eruptions Flashcards
(135 cards)
1
Q
A
Atopic dermatitis
2
Q
What mediates atopic dermatitis
A
IgE
3
Q
What is the epidemiology of atopic dermatitis? Where is it most commonlys een?
A
- Infants and children most often affected
- MC face, scalp, torso, and extensors, flexor folds
- Follicular patterns of atopic dermatitis in persons with darker skin phenotypes
4
Q
Atopic Triad
A
- Eczema (atopic dermatitis)
- Asthma
- Hay fever
5
Q
What are the primary characteristics of atopic dermatitis?
A
- Dry skin and pruritis
- Consequent rubbing –> increased inflammation and lichenification –> further itching and scratching –> itch-scratch cycle
- Itch scratch cycle: itching/scratching –> disrupted skin barrier function–> penetration of allergens and irritants –> inflammation –> itching/scratching
6
Q
Pathophys of atopic dermatitis
A
- Decrease in barrier function due to impaired filagrin production
- Reduced ceramide levels
- Increased transepidermal water loss
- Dehydration of skin
- Acute inflammation associated with IL4 and IL13 expression
7
Q
How can atopic dermatitis be categorized?
A
- Acute - erythema, vesicles, bullae, weeping, crusting
- Subacute - scaly plaques, papules, round erosions, crusts
- Chronic eczema - lichenification, scaling, hyper- and hypopigmentation (depending on Fitzpatrick)
- Itch that rashes
8
Q
Etiology of atopic dermatitis
A
- Genetic and environmental predisposing factors
- Family history increases risk
- Relationship between atopic dermatitis and development of aspirin-related respiratory disease
9
Q
Environmental triggers of atopic dermatitis
A
- Heat
- Humidity
- Detergent
- Soaps
- Abrasive clothing
- Chemicals
- Smoke
- Stress
- Allergy to eggs, cow’s milk, peanuts
10
Q
Hallmark of atopic dermatitis
A
- Intense pruritis
11
Q
Clinical manifestations of atopic derm
A
- Intense pruritis
- Scratching –> lichenification
- Impaired barrier function –> increased water loss and cutaneous infections
- Worry about impetiginization with Staph aureus, secondary HSV, Coxsackie viruses, or vaccinia virus
12
Q
Look for this in atopic derm
A
- scaly, erythematous papules and plaques involving flexural surfaces, particularly antecubital fossae and popliteal fossae, face, neck, and extremities
- Chronic cases –> lichenification, scaling, dyspigmentation
- Facial findings (chronic) = periorbital scaly plaques and thinning of lateral eyebrows
- Periorbital hyperpigmentation
- Hyperlinear palms
- Keratosis pilaris
13
Q
Clinical presenation pearls for AD
A
Adequate history of child and family history of allergies, asthma, and skin disorders
14
Q
Tests for atopic dermatitis
A
- Family and personal history key to diagnosis
- Serum IgE (not necessary but can be done)
- Culture suspected infection
- Skin biopsy can help
15
Q
Management of atopic dermatitis
A
- Avoid triggers
- Appropriate skin care with gentle cleansers (cerave, cetaphil, vanicream fragrance free) and moisturizer on damp skin or under occlusive dressing
- Clearance with lowest strength steroid
- Avoid soap except in body folds
16
Q
Side effects of long term topical steroid usage
A
- Atrophy
- Hypopigmentation
- Striae
17
Q
What localized medications can be used for atopic derm?
A
Steroids 2 weeks out of month
Medium potency:
* triamcinolone cream or ointment BID
* Mometasone cream or ointment BID
* Fluocinolone cream or ointment BID
Low potency:
* Desonide BID
Non steroidal (not recommended in <2 years old):
* Tacrolimus ointment BID
* Pimecrolimus cream BID
* Crisaborole ointment BID
Systemic: dupilumab start 600 mg SC divided into then 300 mg SC q 2 weeks
Medium: TMF (triamcinolone, mometasone, fluocinolone)
18
Q
What can be used for pruritis in atopic dermatitis?
A
Antihistamines!
* Diphenhydramine hydrochloride nightly or every 6 hours as needed
* Hydroxyzine every 6 hours as needed
* Cetirizine hydrochloride 5-10 mg/day
* Loratadine 10 mg tablet or reditab once daily
19
Q
What is contact dermatitis
A
- Acute or chronic inflammatory reactions to substances that come in contact with the skin
20
Q
What is irritant contact dermatitis?
A
- Single exposure to offending agent that is toxic to skin
- Confined to area of exposure and always sharply marginated and never spreads
21
Q
What is allergic contact dermatitis?
A
- Antigen (allergen) elicits type IV hypersensitivity reaction
- Immunologic reaction involves surrounding skin and may spread beyond affected sites
22
Q
Presentation of irritant contact dermatitis?
A
- One exposure to offending agent
- Well demarcated suggestive of outside job or external contact
- Can also present as systemic contact reaction with widespread lesions ie ingested or implanted device
23
Q
Presentation of allergic contact dermatitis
A
- Delayed type (type IV) hypersensitivity reaction = allergens activate antigen-specific T cells in a sensitized individual
- Repeat exposures
- 24-48 hours post exposure
- Topical agents, ingested, implanted devices, airborne
24
Q
Look for what with acute contact dermatitis?
A
- Erythema
- Vesicles
- Bullae
25
Look for what with chronic contact dermatitis?
* Scaling
* Lichenification
* Fissures
* Cracks
* Geometric shapes with well-demarcated borders may be seen
26
What can airborne contact dermatitis affect?
* Face (particularly upper eyelids)
* Neck (including submandibular region)
* Upper chest
* Forearms
* Hands (especially palmar surfaces)
27
What happens with repetitive exposure to the same irritant?
Cumulative contact dermatitis
28
What substances can cause contact dermatitis?
* Soaps, detergents, waterless hand cleaners
* Acids and alkalis 3: hydrofluoric acid, cement, chromic acid, phosphorus, ethylene oxide, phenol, metal salts
* Industrial solvents: coal tar solvents, petroleum, chlorinated hydrocarbons, alcohol solvents, ethylene glycol, ether, turpentine, ethyl ether, acetone, carbon dioxide, DMSO, dioxane, styrene
* Plants: euphorbiaceae (spurges, crotons, poinsettias, manchineel tree), ranunculaceae (buttercup), cruciferae (black mustard), urticaceae (nettles), solanaceae (pepper, capsaicin), opuntia (prickly pear)
* Others: fiberglass, wool, rough synthetic clothing, fire-retardant fabrics, "NCR" paper
29
Diagnostic pearls for contact dermatitis
* Occupational ACD should be considered, particularly in health care professionals, machinists, and construction workers
* Consider allergy adhesive, wound dressings, and/or antimicrobial treatments in patients with chronic wounds including stromas
* Implanted biomedical devices such as pacemakers, orthopedic implants, and endovascular stents can cause
30
Best tests for contact dermatitis
* History and physical exam
* Conduct patch testing to verify allergen (if necessary) --> allergy referral
-positive test does not always equate to diagnosis of ACD and clinical correlation is key
Skin prick tests used to diagnose type I hypersensitivity reactions and are not used for testing for contact dermatitis
31
What defines allergy contact dermatitis?
* Hapten T cell-mediated inflammation
* Reexposure to substance patient has been sensitized to
32
What are possible allergens that can cause allergic contact dermatitis?
* Metal salts to antibiotics
* Dyes to plant products
* Jewelry
* Personal care products
* Topical medications
* Plants
* House remedies
* Chemicals individual may come in contact with at work
33
What is the progression of lesions in allergic contact dermatitis?
Erythema --> papules --> vesicles --> erosions --> crusts --> scaling
34
Management of contact dermatitis?
* Review of medications: OTC/RX/homeopathic
* reduce hot water usage
* Humidifier can be beneficial
* Antihistamines (hydroxyzine vs benadryl)
* do they have animals?
* Avoid offending agents
* Topical steroids (max 2 weeks on, 2 weeks off, repeat)
* Oral steroids
35
What are low potency steroids for contact dermatitis?
* Hydrocortisone 1% cream, ointment
* Hydrocortisone 2.5% cream, ointment
* Desonide ointment twice daily
36
What are medium potency steroids for contact dermatitis?
* Triamcinolone cream, ointment
* Mometasone cream, ointment
* Fluocinolone cream, ointment
37
What are high potency steroids for contact dermatitis?
* Clobetasol cream, ointment
* Halobetasol cream, ointment
* Betamethasone dipropionate cream, ointment
* Fluocinonide cream, ointment
* Desoximetasone cream, ointment
38
What treatment can be used for contact dermatitis that is not medication?
Phototherapy: PUVA
39
What is diaper dermatitis?
* Rash in buttocks region
* Caused by cutaneous candidiasis, ICD, and miliaria (blocked sweat ducts)
* Combination of wet, dark, friction, urine, feces, and microorganisms
* MC in infants 3 weeks old to 2 years old
40
Presentation of diaper dermatitis
* Fussiness
* Crying during diaper changes
* Diarrhea typically multiple (acid in diarrhea can irritate)
* Shiny erythema with dull margins
* +/- papules/vesicles/erosions: candidiasis can be present
* Miliaria: multiple papulovesicular lesions/pruritis
41
Management of diaper dermatitis
* Frequent diaper changes with disposable appropriate fitting diapers
* Keep area dry with blow drier after bathing
* Barrier creams: zinc oxide/petroleum jelly
* If candidiasis: nystatin x 2 weeks
* Clotrimazole x 2 weeks
* Econazole x 2 weeks
42
What is nummular eczema?
* Dermatitis characterized by pruritic, coin shaped, scaly plaques
43
What is nummular eczema associated with?
* Frequent bathing
* Low humidity
* Irritating and drying soaps
* Skin trauma
* Interferon therapy for hepatitis C
* Exposure to irritating fabrics such as wool
* Venous stasis = predisposing factor to developing lesions on legs
* MC in men 50-65 years old
44
Look for what in nummular eczema
* Round or coin-shaped erythematous scaly plaques often with minute fissures, round erosions, or crusts within
* erythema may be less prominent in patients with darker skin phototypes
* Plaques may begin as papules or vesicles which then coalesce
* Trunk and extremities MC
* May involve hands and feet, but not face and scalp
45
Diagnostic pearls for nummular eczema?
* Coin shaped
* Post inflammatory hyperpigmentation
46
Best tests for nummular eczema
* Culture if bacteria suspected
* Skin scraping if fungus suspected
* Biopsy if necessary
47
Treatment for nummular eczema
Same as atopic dermatitis: proper hygiene, lowest strength steroid, avoid triggers
48
What is seborrheic dermatitis?
* Common inflammatory papulosquamous condition
* Affects sebum-rich areas of the body
* Face, scalp, neck, upper chest, and back
* Pityrosporum yeast, a common skin flora
49
Clinical presentation of seborrheic dermatitis
* Simple dandruff fulminant rash
* Dryness
* pruritis
* erythema
* fine greasy scaling
* Scalp, eyebrows, glabella, nasolabial folds, beard area, upper chest, external ear canal, posterior ears, eyelid margins, and intertriginous areas common
* Anogenital involvement also reported
* Darker skin hypo or hyperpigmentation
* Stress can exacerbate
50
What patients may more commonly have seborrheic dermatitis?
* Immunocompromised patients
* HIV = more common
* Parkinsons
51
Look for what in seborrheic dermatitis?
* Erythematous plaques with loose, bran-like, or greasy scale
* Often involving scalp, eyebrows, glabella, beard area, ears, and skin folds, especially nasolabial folds
* Occasionally, crusted plaques are seek
* Lighter skin yellow to red to pink
* Darker skin hypo or hyperpigmentation
* Asymptomatic or may complain of pruritis or burning in affected areas
52
Diagnostic pearls for seborrheic dermatitis
* Facial seborrheic dermatitis may be associated with rosacea
* Psoriasis frequently co-exist
53
Best tests for seborrheic dermatitis
* CLinical diagnosis
* Biopsy may help
* KOH if thinking fungal
54
Management of seborrheic dermatitis
* No cure
* Waxes and wanes
Shampoos
* Salicylic acid
* Selenium sulfide
* Tar shampoos
* Pyrithicone zinc
* ketoconazole shampoo (1st line)
* Vanicream zbar
Steroids
* Clobetasol solution
* Betamethasone
* Fluocinolone scalp oil
* Face hydrocortisone/desonide
55
What is stasis dermatitis
* Inflammatory skin condition occurring on lower extremities caused by chronic venous insufficiency
56
Symptoms of stasis dermatitis
* Pruritis
* Heaviness
* Edema
57
Skin findings in stasis dermatitis
* Erythematous
* Scaling
* Patches
* Weeping
* Crusing
* MC area medial ankle
* Hyperpigmentation late
* Lichenification
* Loss of hair --> shiny skin
58
Management of stasis dermatitis
* Treat underlying VI
* Weeping lesions = wet compresses, clean water and burrows
* Topical steroids: triamcinolone, clobetasol
* Consult vascular
59
Complications of stasis dermatitis
* Cellulitis
* Non healing wounds
60
What is lichen simplex chronicus?
* Lichenified plaques from excessive rubbing and scratching
61
Predisposing factors to lichen simplex chronicus
* Chronic skin conditions
* MC = atopic dermatitis
* Emotional stress
* Habit forming scratching (anxiety)
62
Findings in lichen simplex chronicus
* Thick skin
* Plaques
* Lichenified
* Small papules, hyperpigmentation
* Excoriations
* MC areas: scalp, ankles, lower legs, upper thighs, forearms, vulva, pubis, anal region, scrotum, groin
63
Tretment in lichen simplex chronicus
* Difficult to stop chronic patients from itching
* Stop itch scratch cycle
* Antihistamines?
* Patient education on avoiding scratching
* Trim nails/pressure
* Occlusive dressings/gloves
* Topical steroids: TAC (triamcinolone)
* ILK (intralesional kenalog injections)
* Emollients
64
What is perioral dermatitis?
* Localized inflammatory disorder
* Erythematous papular and pustular eruption
* Involving nasolabial folds, upper and lower cutaneous lip, and chin
* Lip margin and immediate circumoral area typically spared
* Periorbital involvement, predominantly lower and lateral eyelids may occur
* Fine scaling may be seen
* Eruption may be asymptomatic, or burning or itch
* MC women aged between 18 and 40
65
What should be looked for in perioral dermatitis?
* Red papules, both grouped and individually, on the chin, cutaneous lips, and nasolabial folds
* May be pinpoint pustules, may be associated with scaling and erythema
* On occasion, lesions are periocular
* May complain of burning and/or pruritis
66
Best tests for perioral dermatitis
* Clinical diagnosis
* Biopsy can help
67
Management pearls for perioral dermatitis
* If perioral dermatitis triggered by use of mid- or high-potency topical steroids, then use low-potency to taper because will flare if CS discontinued abruptly
* Warn that will likely flare before they improve after steroid stopped
68
Therapy for perioral dermatitis
* DC topical steroids (taper)
* Topical pimecrolimus 1% every 12 hours
* Topical and oral antibiotics, avoid use of gels, solutions, or lotions on eyelid --> erythromycin every 12 hours or metronidazole every 12 hours or clindamycin every 12 hours
* Topical azelaic acid every 12 hours
* Doxycycline if necessary
69
What is dyshidrotic eczema?
* Common on hands and feet
* Pruritic vesicular rash
* Typically history of atopic dermatitis
* MC between 20-40 years old
## Footnote
Tapioca like vesicles on lateral aspects of digits
70
Symptoms of dyshidrotic eczema
* Itching
* Burning
* Pain
71
Tests for dyshidrotic eczema
* C&S if unsure if infection or not
* Patch testing (not always necessary)
* Biopsy - diagnostic
72
Treatment of dyshidrotic eczema
* Topical steroids
* Under occlusion x 2 weeks
* Severe = high dose PO prednisone 2 week taper
* PUVA therapy
## Footnote
can use norwegian neutrogena with gloves
73
How is a secondary bacterial infection due to dyshidrotic eczema treated?
* PO ABX vs topical
74
What is the course of dyshidrotic eczema?
* Course chronic, relapsing
* Spotaneous remission (clinically not usually true)
* Improves with age
75
Patient education for dyshidrotic eczema
* Avoid allergens/irritants
* Excessive hand washing
76
What are emollients?
* Non-cosmetic moisturizers
* Increase skin moisture, flexibility, and prevent cracking/fissures
* Use unscented and without anti-aging ingredients
77
How should emollients be applied?
* Immediately after bathing and frequently throughout day (3x/d)
* Apply in direction of hair growth
* Avoid excessive rubbing
* Continue use after flare up is controlled
78
What are benefits of cream emollients?
* Best option for most dermatoses
* Mixture of fat and water
* Cooling effect on skin
* Moderate moisturizing effect
79
What are characteristics of lotion emollients?
* More water, less fat than cream
* Less effective at moisturizing skin
* Useful for hair covered areas
80
What are characteristics of ointment emollients?
* Greasy; avoid on weeping eczema
* Preferable for dry/thickened skin
81
MOA of topical corticosteroids (glucocorticoids)
* Decreases immune response by 4 different processes
* Stabilizes leukocyte/macrophage/histamine activity
* Constriction of the capillaries and reduced capillary wall permeability- improving and preventing edema formation
* Decreases activation of complement cascade
* Reduces fibroblast proliferation and collagen deposition which leads to reduced scar formation
82
Indications for topical corticosteroids
* Atopic/seborrheic, contact dermatitis
* Lichen simplex
* Pruritis ani
* Nummular eczema
* Stasis dermatitis
* Psoriasis
83
Contraindications for topical corticosteroids
* Underlying bacterial infections
* Hypersensitivity
* Ophthalmic use
84
Cautions for topical corticosteroids
* Chronic use may inhibit growth in children
* Chronic use induced Cushing syndrome, Kaposi sarcoma
85
Pregnancy category of topical corticosteroids
C
86
Classification of potency of corticosteroids
* Class I-VII
* I: highest
* VII: lowest
87
When are side effects of topical corticosteroids more likely to be seen
* Continuous long term use
* High potency steroids/vehicles
* Facial, intertriginous, genital dermatoses
88
Side effects of topical corticosteroid
* Skin atrophy
* Striae
* Easy bruising
* Telangiectasias
* Change in skin pigmentation
* Corticoid rosacea
* Steroid acne
* Adrenal suppression
* Glaucoma (periorbital use)
89
Characteristics of ointment as a topical corticosteroid vehicle
* Semi-occlusive
* Petroleum based
* Most potent
* Benefits: superior lubrication, prevention of moisture loss, increase active ingredient absorption
* Disadvantages: greasy, avoid hairy areas
90
Characteristics of creams as topical corticosteroid vehicle
* Semisolid emulsions of oil in 20-50% water
* Less potent vehicle
* Benefits: cosmetic absorption
91
Characteristics of lotion as corticosteroid vehicle
* Powder in water - requires shaking of container prior to use
* Least potent vehicle
* Benefits: minimal residue, cooling/soothing to skin, covers large area, good for thick hair bearing areas
92
Characteristics of gels as corticosteroid vehicle
* Mixture of oil in water with alcohol base
* Drying effect with minimal residue
* Great for scalp dermatitis or acne
* No residue
93
Characteristics of powders as corticosteroid vehicles
* Absorb excess moisture
* Protect skin-skin chafing
* Covers large area
94
Characteristics of foam as corticosteroid vehicle
* Gaseous bubbles of matrix of liquid film
* Easy to spread, w/o residue
* More expensive
95
Characteristics of solution as topical corticosteroid vehicle
* Low viscosity
* Powder in water/alcohol
* Alcohol - drying effect
96
What is the lowest potency topical corticosteroid (class VII)
hydrocortisone
97
what is the low potency topical steroid (class VI)?
triamcinolone .025%
98
what are the med/low potency topical corticosteroids (Class V)
* Hydrocortisone valerate .2%
* Triamcinolone .1% or .025%
* Betamethasone valerate .1% c, l
* Betamethasone dipropionate .05% l
99
what are the medium potency topical steroids
* hydrocortisone valerate .2% o
* triamcinolone .1% o
* betamethasone valerate .12% f
100
What are the medium high potency corticosteroids (class III)
* triamcinolon .5% c
* betamethasone valerate .1% o
* betamethasone dipropionate .05% c
101
what are the class II (high potency) topical corticosteroids
* triamcinolone .5% O
* betamethasone dipropionate .05% o
* fluocinonide acetonide .05% cogs
102
what is the class I topical corticosteroid
fluocinonide acetonide .1% c
103
dosing of corticosteroids
qd-bid
104
tapering treatment of topical corticosteroids
* gradual reduction in potency and frequency of application
* 1-2 week intervals between each reduction in dose
105
Maximum duration of treatment
* Class I = <3 wk
* Class II - IV = <6-8 wk
* Class V-VII = chronic intermittent therapy, but face, intertriginous, genital limit to 1-2 wk intervals of therapy
106
Maintenance therapy with topical corticosteroids
* Lowest dose/regimen possible while maintaining control
* Switch to less potent agent for long term therapy
107
What is tachyphylaxis
* Progressive decrease in clinical response to same dose
* Results fro repetitive use of same drug
* Prevented by drug free intervals "holidays" and switching to alternative agent
108
Calcineurin inhibitors
* Pimecrolimus 1% cream
* Tacrolimus .03%, .1% ointment
109
MOA of calcineurin inhibitors
* Inhibits t lymphocyte activation via calcineurin inhibition
* Prevents release of inflammatory cytokines/mediators
110
Dosing of calcineurin inhibitors
BID until clearing is noted
111
Indications for calcineurin inhibitors
* Atopic dermatitis
* Off label- intertriginous and facial psoriasis, oral lichen planus; vitiligo
112
Maximum duration of therapy of calcineurinn inhibitors
* Pimecrolimus- 2 years
* Tacrolimus - 4 years
113
Black box warning for pimecrolimus and tacrolimus
* Rare case of lymphoma and skin malignancy
* Avoid long term use
* Limit to areas of AD, with minimal application to maintain control
114
Contraindications for immunomodulators
* Hypersensitivity
* <2 yo
115
Cautions with pimecrolimus/tacrolimus
* Do not use with occlusive dressing
* Reassess if no improvement in 6 weeks
* Pregnancy category C
116
SE of immunomodulators
* Burning sensation (MC) resolves with continued use
* HA
* URI symptoms, fever
117
Pros of immunomodulators
* No skin atrophy/striae
* Safe for use on face/eyelids
118
Cons of immunomodulators
* More expensive
* Black box - tumorigenicity
119
What is selenium sulfide found in?
* Head and shoulders
* Selsun
120
MOA of selenium sulfide
* Not fully known
* Reduction in corneocyte production
121
Indications for selenium sulfide
* Seborrheic dermatitis
* Tinea versicolor
122
Contraindications for selenium sulfide
* Hypersensitivity
* Oral, opthalmic, anal, or intravaginal use
123
Vehicles of selenium sulfide
* Shampoo
* Lotion
* Foam
124
Dosing of selenium sulfide
* Seborrheic dermatitis: apply to affected area for 2-3 mins, rinse thoroughly, repeat 2x/wk initially; maintenance therapy once q 1-2 weeks
* Tinea versicolor: shampoo/lotion: apply to affected area, lather, leave for 10 mins, rinse thoroughly; apply QD for 7 days
* Foam: rub into affected area q 12 h x 7 days
125
SE of selenium sulfide
Transient burning, stinging
126
What contains pyrithione zinc?
* Head and Shoulders
* Selsun
* T/Gel
127
MOA of pyrithione zinc
Binds to hair/skin and reduces cell turnover
128
Vehicle of pyrithione zinc
Shampoo, lotion, cream, soap bar
129
Indications for pyrithione zinc
Seborrheic dermatitis
130
Contraindications for pyrithione zinc
Hypersensitivity
131
Side effects of pyrithione zinc
* Transient stinging/burning
* Desquamation
132
Dosing of pyrithione zinc
* Shampoo: apply to wet hair/scalp, lather, rinse thoroughly
* Bar: massage into wet area, rinse
133
A 75 year old with a history of Parkinson's disease presents with minimally pruritic facial lesions presenting for 1 week. Exam reveals scattered discrete macules approximately 1 cm in size, with an orage-red greasy scale on the cheeks and nasolabial folds. What is the most appropriate treatment?
* Hydrocortisone cream
134
A 47 year old male presents with worsening irritation of his hand that started as dryness and progressed to chapping and erythema and now has fissuring. He works as a janitor inn the local hospital cleaning the operating rooms. His symptoms become less severe on his days off. What advice should be offered?
Wear appropriate protective clothing and equipment
135
A 22 year old female is complaining of a rash around her mouth. She describes a feeling of mild burning or tension but denies pruritis. Exam reveals papulospustules on erythematous bases, the vermillion border is spared. A culture is negative. What is the recommended management?
Topical metronidazole (could also use topical erythromycin)
