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Pediatric Primary Care TEST 2 > Dermatology > Flashcards

Flashcards in Dermatology Deck (51):
1

Dermatitis

• 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

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Multiple types of dermatitis:

o 1. Seborrheic

o 2. Atopic

o 3. Dyshidrotic

o 4. Nummular

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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

4

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

5

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

6

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

7

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)

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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

9

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)

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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***

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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**

12

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.)

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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

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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

LEAVES OF 3 LET THEM BE

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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!)

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What should you use for drying weeping allergic contact derm?

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

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Linear Streaks

Koebner phenomenon

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Fomites can be contaminated by...

the plant oil and lead to recurrent eruptions

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Contact dermatitis; topical steroid level

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

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

o Usually scattered

o Not linear or grouped

o No history of multiple bites

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Rhus Dermatitis Mimics of Lesions -- Cellulitis

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

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Rhus Dermatitis Mimics of Lesions -- Herpes Zoster

Painful eruption of grouped vesicles in a dermatomal distribution

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Rhus Dermatitis Mimics of Lesions -- Urticaria

o MOVING edematous plaques, not vesicles

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

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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

25

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

26

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

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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

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HISTORY TAKING FOR Dermatitis

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

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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

30

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

31

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

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POSITIVE PATCH TEST

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

33

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

34

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*

35

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

10%

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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

37

S from SCRATCH

  • 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

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R stands for

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

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A stands for

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

40

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.

41

C stands for

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

42

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

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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.

44

Irritant Contact Dermatitis

Overview

  • 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)

45

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

46

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

47

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

48

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

49

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
    • PATCH to ALLERGY

50

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

51

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.