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Pediatric Primary Care TEST 2 > Dermatology > Flashcards

Flashcards in Dermatology Deck (51):


• Dermatitis or eczema is a pattern of cutaneous inflammation that presents with erythema, vesiculation, and pruritus in its acute phase

•The chronic phase is characterized by dryness, scaling, lichenification, fissuring, and pruritus


Multiple types of dermatitis:

o 1. Seborrheic

o 2. Atopic

o 3. Dyshidrotic

o 4. Nummular


Seborrheic Dermatitis

• Affect person in post puberty

• Pityrosporum Ovale, lipophilic yeast of Malassezia genus

• May induce inflammatory response

• Present on all person

• Responds to antifungal

• Infancy and adolescence


CLINICAL PRESENTATIONS of Seborrheic Dermatitis

Affect area where sebaceous blends in high frequency and are most active

♣ Scalp

♣ Eyebrows

♣ Eyelashes

♣ Forehead

♣ Nasolabial fold (common in kids with CP)

♣ External ear canal

Also found near umbilicus, under breast


Treatment for Seborrheic Dermatitis (4)

  • Under androgen control - responds well to anti-fungal shampoo
  • Frequent cleansing with soap removes oils
  • Outdoor recreation improve seborrhea
  • Avoid sun damage


Antidandruff Shampoo

  • 2.5% percent selenium sulfide
  • 1-2% pyrithione zinc
    • Head and Shoulders
  • Coal Tar
  • OTC Ketoconazole shampoo treats the fungus infection; can rotate with Coal Tar


Some popular name brands - Antidandruff shampoo

OTC with salicylic acid --> X-Seb, Scalpicin Pyrithione Zinc 1% --> Head and shoulder, Zincon, Dandex Pyrithione Zinc 2% --> DHS zinc, Theraplex Z Prescription medicine selenium sulfide Selsun, Exsel) or pyrithione zinc DHS Zinc, Head & Shoulders Shampoos with coal tar DHS Tar, Neutrogena T/Gel, Polytar may be used 3 times a week Carmol HC ♣ Contains urea smoothing agent; takes top layers of skin and smooth them down ♣ Not aesthetic because urea burns Elidel off-label use; calcium inhibitor and very good for seborrhea (BBW and high lymphoma risk)


TREATMENT: Special Considerations for African Americans Seborrheic Derm

  • Use of daily shampooing not applicable
  • Weekly shampooing
  • Fluocinolone acetonide in oil as pomade
  • Other option
    • Moderate to mid potency topical
  • Corticosteroid in ointment base
  • Some AA children do not wash hair everyday because it would dry out
    • Use with mid-strength steroid to clear it up


Contact Dermatitis 2 types

Skin condition created by a reaction to an externally applied substance

Types of contact dermatitis:

o Irritant Contact Dermatitis (ICD)

o Allergic Contact Dermatitis (ACD)


Allergic Contact Dermatitis Overview

  • ACD occurs when contact with a particular substance elicits a delayed hypersensitivity reaction
  • The sensitization process requires 10-14 days
  • Upon re-exposure, dermatitis appears within 12-48 hrs
  • The most common cause is Rhus dermatitis, from poison ivy, poison oak, or poison sumac (all contain the resin – urushiol) T-cell mediated***


Other common causes of A Contact Derm (9)

o Fragrances

o Formaldehyde

o Preservatives

o Neosporin

o Benzocaine

o Vitamin E

o Rubber compounds

o Nickel -- Number 1 contact dermatitis

o Balsam of Peru -- ALL MAKE-UP**


Clinical Findings of Atopic Contact Dermatitis

  • Main symptom of ACD is pruritis
    • Weepy, huge amounts of vesicles Bilateral
  • Presents as eczematous, scaly edematous plaques with vesiculation distributed in areas of exposure
  • ACD is bilateral if the exposure is bilateral (e.g., shoes, gloves, ingredients in creams, etc.)


Poison oak leaves are usually (5)

o Are 3‐7cm in length

o Lobulated notched edges

o Groups of 3, 5, or 7

o Grows on bush‐like plants

o Turn colors in autumn


Poison Ivy leaves are usually

o Are 3‐15cm in length

o Notched edges o Groups of 3s

o Grows on hairy‐stemmed vines or low shrubs

o Turn colors in autumn



Rhus Allergy Initial episode

Subsequent outbreaks

Total length Initial episode

  • The initial episode occurs 7-10 days after exposure
  • On subsequent outbreaks the rash may appear within hours of exposure and usually within 2 days
  • Individual sensitivity is variable so the eruption may be mild to severe
  • Rhus dermatitis lasts from 10-21 days depending on the severity
  • Initial episode is the longest (up to 6 weeks!)


What should you use for drying weeping allergic contact derm?

BURROWS solution -- covered under medicaid phenomenal for drying up weeping allergic contact dermatitis


Linear Streaks

Koebner phenomenon


Fomites can be contaminated by...

the plant oil and lead to recurrent eruptions


Contact dermatitis; topical steroid level

3 along with anti-itch medication (aveeno, eucerin)


Rhus Dermatitis Mimics of Lesions -- Bullous insect bites (3)

o Usually scattered

o Not linear or grouped

o No history of multiple bites


Rhus Dermatitis Mimics of Lesions -- Cellulitis

  • Spreading erythematous, non-fluctuant tender plaque
  • Can be associated with fever


Rhus Dermatitis Mimics of Lesions -- Herpes Zoster

Painful eruption of grouped vesicles in a dermatomal distribution


Rhus Dermatitis Mimics of Lesions -- Urticaria

o MOVING edematous plaques, not vesicles

o Early lesions of allergic contact dermatitis could be mistaken for urticaria


Rhus Dermatitis Treatment

  • Most patients need minor supportive care
    • Topical steroids for localized involvement
    • Topical or oral antihistamines may improve pruritus
    • Oatmeal soaks/calamine lotion may soothe weeping erosions
  • Severe involvement may require oral steroids
  • In cases of failing potent topical steroids, or widespread
    • If given for less than 2-3 weeks, patients may relapse
    • Do not give short bursts of steroids for this reason


Rhus Allergy Prevention

  • Avoid the plants
  • Wash clothing, shoes, and objects after exposure (within 10 minutes if possible)
  • Apply barrier: clothing, OTC products which bind resin more than skin


Eyelid Allergic Contact Dermatitis Common Causes

Intensely pruritic

• Scaling red plaques on upper > lower eyelids

• Allergic contact dermatitis of the eyelid is often caused by transfer from the hands

• Common causes:

  • Nail adhesive/polish
  • Fragrances and preservatives in cosmetics -- Balsam of Peru
  • Nickel


Evaluation of Dermatitis

  • • Important to take a comprehensive history
    • Ask questions about possible culprit
    • Think about what they might be doing
  • Complete dermatologic assessment of the patient
  • Shape, configuration, and location of the dermatitis are useful clues in identifying the culprit allergen
  • Elimination of a suspected trigger may be both diagnostic and therapeutic
  • In chronic cases, patch testing is necessary to identify specific allergens



o In addition to the dermatitis-specific history (e.g., onset, location, temporal associations, treatment), be sure to ask about:

  • Daily skin care routine
  • All topical products
  • Occupation/hobbies
  • Regular and occasional exposures (e.g. lawn care products, animal shampoos)

Are they washing their dog with flea shampoo? Hobby, recreation


Steroid Potency

Regular use of Class 1, 2, or 3 steroids on thin skin will lead to steroid atrophy (thinning and easy bruising/purpura)

o Also hypopigmentation in darker skin types

If topical steroids are to be used on the eyelid for a period of more than one month, refer to an ophthalmologist for monitoring of intraocular pressure and the development of cataracts


Steroid Potency FOR THE FACE

For the face:

  • Class 6, 7 steroids (e.g., desonide) can safely be used intermittently during flares
  • Hydrocortisone cream 1%
  • Elidel and protopic (Black Box Warnings) ELIDEL -- Works for contact derm around eyes


PATCH testing (6)

• Patch testing is used to determine which allergens a patient with allergic contact dermatitis reacts against

• A series of allergens are applied to the back, and they are removed after 2 days

• On day 4 or 5, the patient returns for the results

• Positive reactions show erythema and papules or vesicles

• Identification of specific allergens helps the patient find products free of those allergens

• Example of a patient with patches (allergens) placed on the back o Best test for allergic contact dermatitis



Positive patch test reactions at 96-hour reading

This patient had three positive reactions

♣ Nickel, Balsam of Peru, and Fragrance Avoidance of these allergens should improve their rash


Identifying Allergens

• Not all patients with ACD need patch testing

• Refer patients when the allergen is unclear or the dermatitis is chronic

• A positive reaction on patch testing does not mean that the patient’s rash is due to that specific allergen

• Elimination of the rash with removal of the allergen confirms the clinical relevance of the positive patch test


ACD Treatment

• Avoid exposure to offending substance

• Treatment of the acute phase depends on the severity of the dermatitis

  • In mild to moderate cases, topical steroids of medium to strong potency for a limited course is successful
  • A short course of systemic steroids may be required for acute flares
  • Oatmeal baths or soothing lotions can provide further relief in mild cases
  • Wet dressings are helpful when there is extensive oozing and crusting BURROWS*


Chronic cases or patients with dermatitis involving over _____ of the BSA should be referred to a dermatologist



Latex Allergy

  • Delayed hypersensitivity: Patients develop an allergic contact dermatitis
    • Often presents on the dorsal surface of the hands
  • Immediate hypersensitivity: May present with immediate symptoms such as burning, stinging, or itching with or without localized urticaria on contact with latex proteins
    • May include disseminated urticaria, allergic rhinitis, and/or anaphylaxis #1 allergen that will go from a localized reaction to systemic reaction
  • Can get type 1 reaction after years of having a type 4 T-cell mediated allergic reaction



  • stands for symmetrical.
    • Commonly affected areas include exposed surfaces such as the face, neck, arms, and legs
    •  Covered areas such as the abdomen, palms, soles, diaper area, etc. are spared. C stands for cluster.
    • Lesions usually appear in a “meal cluster,” that is often described as “breakfast, lunch, and dinner.” This grouping of lesions are characteristic of bedbug bites, but also are seen in flea bites and with IBIH.
      • Appear in a meal cluster; breakfast, lunch and dinner


R stands for

  • Rover
    • Is there is a family pet where the child could come into contact with fleas?


A stands for

  • age.
    • IBIH is rarely seen in babies, and these reactions peak after the age of 2.


T stands for

  • Target and time.
    • Target lesions are characteristic for IBIH, particularly in dark‐pigmented patients. Time refers to the chronic nature of this condition.


C stands for

  • confused.
    • Patients and their parents are often confused/surprised that these reactions are due to bugs.


H stands for

  • history.

IBIH is not often associated with family history, unlike with scabies and atopic dermatitis where we see a strong family history correlation


3 P's for Insect Bites

  • Prevention
    •  Wearing protective clothing for outdoor play with use of insect repellents.
  • Patience
  • Pruritis control
    • Topical steroids may help
      • Due to depth of inflammatory, topical agents can ineffective.
      • Use of antihistamine
        • Little evidence to support due to the predominance of Tcell–mediated response and a lack of histaminemediated lesions.


Irritant Contact Dermatitis


  • Inflammatory reaction in the skin resulting from exposure to a substance that can cause an eruption in most people who come in contact with it
  • Strictly on hands – most likely irritant contact dermatitis
  • No previous exposure is necessary
  • May occur from a single application with severely toxic substances
  • Most commonly results from repeated application from mildly irritating substances (e.g., soaps, detergents)


Multifactorial disease where...

Most important exogenous factor for ICD

Areas that are most susceptible

  • Multifactorial disease where both exogenous (irritant and environmental) and endogenous (host) elements play a role.
    • Most important exogenous factor for ICD is the inherent toxicity of the chemical for human skin
    • Site differences in barrier function, making the face, neck, scrotum, and dorsal hands more susceptible


Major Risk Factor for Irritant Hand Derm

  • Atopic dermatitis is a major risk factor for irritant hand dermatitis because of impaired barrier function and lower threshold for skin irritation
    • More likely to get irritant CD
    • When you go to apply a moisturizer for atopic derm you need to be careful because if they do travel – using a moisturizer that doesn’t have a lot of chemicals in it


ICD Clinical Findings

  • Mild irritants produce
    • Erythema
    • Chapped skin
    • Dryness
    • Fissuring after repeated exposures over time
  • Pruritus can range from mild to extreme
  • Pain is a common symptom when erosions and fissures are present
  • Severe cases present with edema, exudate, and tenderness
  • Potent irritants produce painful bullae within hours after the exposure


What to use for Itch (5)

  • Topical steroids
  • Antihistamines
    • Only provide relief when pruritus is mediated by antihistamine as in case of urticaria
    • Eczema—anti histamine does not work
  • Pramoxine
    • Topical anesthetic
      • Aveeno anti itch
      • Eucerin calming cream
      • Pramasone
  • Capsaicin
    • Capzasin cream activate the TRP-V1 channel to produce mildly painful sensation and interferes with itch
    • Used for bug bite*
  • Menthol
    • Topical ant-itch product—Sarna, and aveeno
    • Activates TRP channels to create a competitive sensation to itch
    • Vicks vapor rub


ICD Evaluation and Treatment

  • Identification and avoidance of the potential irritant is the mainstay of treatment
    • Need to avoid whatever causes it
  • Topical therapy with steroids to reduce inflammation and emollients to improve barrier repair are usually recommended
  • Referral to a dermatologist should be made for patients who are not improving with removal of the irritant or in severe cases
  • Patch testing should be performed in occupational cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis


ICD prevention

  • Patient Education about things the irritant is included in
    • Need to read and be able to look for it
  • Use personal protective equipment (e.g. protective gloves should be worn for any wet work)
  • Instead of soap, use less irritating substances, such as emollients and soap substitutes when washing
    • Only recommend: White Dove for soap
  • Care should be taken for several months after the dermatitis has healed, as the skin remains vulnerable to flares of dermatitis for a prolonged period


Take Home Points

  • Allergic contact dermatitis (ACD) and Irritant contact dermatitis (ICD) are the two types of contact dermatitis.
  • ACD occurs when contact with a particular substance elicits a delayed hypersensitivity reaction.
    • ACD = delayed T-cell hypersensitivity reaction
  • Most patients need minor supportive care, but some cases will require oral steroids.
  • Patch testing is used to determine which allergens a patient with allergic contact dermatitis reacts against.
  • Not all patients with ACD need patch testing.
  • Latex allergy may present as a delayed or immediate hypersensitivity.
    • Can go from type 4 to type 1 anaphylaxis
  • ICD is an inflammatory reaction in the skin resulting from exposure to a substance that can cause an eruption in most people who come in contact with it.
    • Inflammatory
  • Identification and avoidance of the potential irritant is the mainstay of treatment.
  • Patch testing may be performed in cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis.
  • If a rash is due to an exposure at work, the medical evaluation may be covered by worker’s compensation.
  • Important to ask about the patient’s occupation/school related activity
  • Referral to a dermatologist should be made for patients with contact dermatitis who are not improving with the removal of the allergen/irritant or severe cases.