Dermatology Dermatitis, Autoimmune Flashcards
(66 cards)
1
Q
Dermatitis Types
Acute (2)
Chronic (5)
A
- Urticaria (Hives)
- Contact dermatitis
- Eczematous or atopic dermatitis
- Seborrheic dermatitis
- Psoriasis
- Acne Vulgaris
- Rosacea
2
Q
Transient, pruritic, erythematous, edematous, papules, plaques, and wheals
Affects 20% of general population
Usually occurs over 1-2 hours, uncommon for lesions to remain on skin >24hrs
A
Urticaria (Hives)
3
Q
Urticaria (Hives)
- Common triggers =
- Often the trigger is (1)*
- May be accompanied by (1)*→ monitor (1)*
- (1) = consider if lesions continue to appear more than 6 weeks
A
- Foods, meds, cold, infection, stress, contact w substances, water
- Idiopathic
- Angioedema (lips, throat, eyes) → Monitor airway
- Chronic urticaria
- Angioedema d/t severe allergic reactions. Occurs often in African Americans who take ACE inhibitors*
- Chronic urticaria is much more difficult to find a cause for*
4
Q
What condition is shown in these pictures?
A
Dermatographia
(Urticaria)
5
Q
Urticaria Treatment
Treatment is symptomatic
Rx (4)
Pregnant Rx (2)
Nursing Rx (1)
A
-
H1 Antihistamines
- 1st generation (sedating) - Diphenydramine 50mg, Hydryzine (Atarax) 10, 25, 50mg
- 2nd generation (first line bc less sedating) - Cetirizine (Zyrtec) 10mg, Loratidine (Claritin) 10mg, Fexofenadine (Allegra) 180mg, Levocetirizine (Xyzal) 5mg
-
H2 Antihistamines
- Combo with H1 is more effective (urticaria often occurs when too much histamine is released)
-
H2 Blockers
- Famotidine (Pepcid)
-
Glucocorticoids
- Only if initial sx are severe, as with prominent angioedema
- ADD to antihistamines and H1 blockers as need those to stabilize mast cells
Pregnant (Chlorpheniramine 4mg Q4-6h PRN or Benadryl)
Loratidine 10mg QD
6
Q
Any dermatitis arising from direct contact to a substance
(2) Types + Associated symptom of each (2)
A
Contact Dermatitis
- Allergic Dermatitis (pruritis) = occurs when substance triggers delayed type IV, T-cell mediated hypersensitivity response
- Irritant Dermatitis (burning) = trigger substance directly damages skin causing cutaneous inflammation
7
Q
Contact Dermatitis: Allergic Type
- S______ requires 10-14 days
- Upon re-exposure → ______ released dermatitis within 12-48 hours
- Examples: Poison I___/O___/S____, Ni___, Dy__, Fr_____, Balsam of P____, OTC topical antibiotics (2), Ru_____
A
- Sensitization requires 10-14 days
- Upon re-exposure → cytokines released dermatitis within 12-48 hours
- Examples: Poison Ivy/Oak/Sumac, Nickel, Dyes, Fragrances, Balsam of Peru, OTC topical antibiotics (Neosporin, Bacitracin), Rubber
8
Q
Contact Dermatitis
What substance in Poison Ivy, Mangoes, and Ginkgo lead to a reaction?
Assess for ____ streaks which is common in poison ivy
A
Oleoresin Urushiol
Linear streaks common in poison ivy (vesicles, bullae, and edema are present)
9
Q
What is causing the contact dermatitis in these images?
A
Nickel from earrings/belt, Rubber from sandals
10
Q
Poison Ivy Non-Pharm Treatment
- First ____ offending agent!
- Gently _____ everything that may have had contact with it w soap and water including skin
- _____ baths and ____ wet compresses may soothe
- Weepy blisters: (1) solution on wet occlusive dressing
A
- First remove offending agent!
- Gently wash everything that may have had contact with it w soap and water including skin
- Oatmeal baths and cool wet compresses may soothe
- Weepy blisters: Domborows solution on wet occlusive dressing
11
Q
Poison Ivy Pharm Treatment
- 1st line = (1) (clobetasol, fluocinonide)
- NOT on (2) places → due to skin atrophy
-
(1)??—commonly used, not well studied
- Sedating may help with sleep if pruritus keeping awake
-
(1) if severe or large BSA affected
- 60 mg/day starting dose (1mg/kg/day)
-
Gradually _____ over 2-3 weeks to prevent rebound sx
- __ MEDROL OR STEROID PACKS – not long enough treatment
A
- High potency steroid creams 1st line (clobetasol, fluocinonide)
- NOT on face, genitals → due to skin atrophy
- Antihistamines ??—commonly used, not well studied
- Sedating may help with sleep if pruritus keeping awake
- Systemic steroids if severe or large BSA affected
- 60 mg/day starting dose (1mg/kg/day)
-
Gradually taper over 2-3 weeks to prevent rebound sx
- NO MEDROL OR STEROID PACKS – not long enough treatment
12
Q
Testing you could do to help find out what is causing contact dermatitis?
A
Patch Testing
13
Q
Latex Allergy
Latex natural product from rubber tree H____ br_____
- Common allergen to people w/ _____ latex exposure
- nonspecific sx & lack of knowledge → _____ diagnosis
- exposure may be _____ → powders used in gloves
- may progress rapidly and unpredictably to ______
- Dx =
- Rx =
A
Hevea Brasiliensis
- Common allergen to people w cumulative latex exposure
- nonspecific sx & lack of knowledge → missed diagnosis
- exposure may be airborne → powders used in gloves
- may progress rapidly and unpredictably to anaphylaxis
- Dx = made by history - may confirm with skin testing
- Rx = educate, avoidance, antihistamines, Epipen prn
14
Q
Contact Dermatitis Treatment
The KEY is?
Work with patient to help them be their own _____ OR ____ testing
- Topicals for symptomatic treatment
- (1) = Mainstay of treatment
- (1) = May be preferred for persistent facial particularly periocular dermatitis
- (1) = May help diminish pruritis caused by allergic contact dermatitis
- TCI’s has block box warning but not for topical
A
Removal of Offending Agent
Work with patient to help them be their own detective or patch testing
- Topicals for symptomatic treatment
- High potency topical glucocorticoids (not for face)
- Topical Calcineurin Inhibitors (immunomodulators) - Pimecrolimus (Elidel) or Tacrolimus
- Oral antihistamines
15
Q
Commonly Prescribed Corticosteroids
Strength based on (2) of rash
A
Strength based on location and severity of rash
16
Q
38 yo male with pruritic rash for several weeks; sx are intermittent. Well-circumscribed scaly erythematous patch area or erythema and with excoriations. What is the most likely diagnosis?
- Tinea corporis
- Contact dermatitis
- Urticaria
- Herpes simplex
- Herpes Zoster
What is the most critical aspect of managing this?
What is the first line medical therapy for symptom relief?
- Acyclovir 5% cream
- Econazole 1% cream
- Diphenhydramine (Benadryl) tabs 50 mg
- Triamcinolone acetonide ointment 0.1%
A
- Tinea corporis
- Contact dermatitis
- Urticaria
- Herpes simplex
- Herpes Zoster? - no vesicles, and usually gone within 7-10 days
Minimizing contact with the offending agent
- Acyclovir 5% cream
- Econazole 1% cream
- Diphenhydramine (Benadryl) tabs 50 mg
- Triamcinolone acetonide ointment 0.1%
17
Q
Chronic, inflammatory condition causing overproduction of skin cells, sebum, and normal yeast
debate re: if belongs in fungal section vs idiopathic
- Typically areas w/many _____ glands (___-producing glands)
- Commonly affected areas (5)
- _______ is mild form
A
Seborrheic Dermatitis
- Typically areas w/many sebaceous glands (oil-producing glands)
- Scalp (appears weepy), upper chest, back, face (eyebrows, NLFs, hairline), ears
- Dandruff is a mild form
18
Q
Seborrheic Dermatitis Characteristics
- Symptoms are in_____, s_____, st___-related
- Pruritic o____, r___ patches with significant y____ and w____ sc____
- Note: POC may exhibit ___pigmented scaly patches
- Dx =
- DDx =
A
- Symptoms are intermittent, seasonal, stress
- Pruritic orange, red patches with significant yellow and white scales
- POC may exhibit hypopigmented scaly patches
- Dx = based on exam and history (rarely skin biopsy)
- DDx = eczema, psoriasis, PR, contact derm, lupus, rosacea, tinea capitus
19
Q
Seborrheic Dermatitis Treatment
First line agent (1)
+ (1) if moderate or severe or PRN for pruritis
Alternative to anti-fungal (1)
A
Topical Antifungals (if mild)
+/- low potency topical steroids for mod-severe inflammation and pruritis
Anti-seborrhea shampoos (helps control itch, scaling, and dandruff)
20
Q
Seborrheic Dermatitis Topical Antifungals
- (1): cream; gel; shampoo (Nizoral) 2% (prescription) or 1% (OTC);
- (1) (Loprox)- Cream/lotion/gel: 0.77%; Shampoo: 1%
How frequent to use Creams? How frequent to use Shampoos? OTC anti-seborrhea shampoos how often?
A
- Ketoconazole cream, gel, or shampoo
- Ciclopirox cream, lotion, gel
Creams BID, Shampoos 3x weekly, OTC anti-seborrhea every other day
21
Q
Anti-Seborrhea Shampoos Instructions
- Requires min __ weeks
- Leave on for _ - _ minutes then rinse well (3-4x/wk)
Examples of Anti-Seborrheic Shampoos (3)
A
- Requires min 4 weeks
- Leave on for 5-10 min, then rinse well (3-4x/wk)
OTC Anti-seborrheic/Anti-inflammatory shampoo
- Tar (Z-tar, T-gel)
- Selenium sulfide (Selsun, Exelderm)
- Zinc pyrithione (Head and shoulders, Zincon)
If 1 shampoo doesn’t work after 4-6 wks, try 1 w/diff active ingredient, combo antifungal + anti-inflammatory
22
Q
Seborrheic Dermatitis Cradle Cap Considerations
- Affects (1), most cases will resolve (1)
- Apply (2) oil gently to scales prior to bathing
- Do not ____ scalp, gently remove scales with a (1)
- Can use (2) shampoos
- Low potency (1) ie 1% hydrocortisone cream or lotion for a few days if severe and itchy
A
- Very young infants, most cases will resolve on their own
- Mineral oil or baby oil before bathing
- Selenium Sulfide or Ketoconazole shampoo
- Low potency corticosteroids (1% hydrocort) if severe and itchy
23
Q
Chronic inflammatory, pruritic skin disease, usually appears in childhood
“The rash that itches”
- Caused by both (1) and (1) factors that lead to a disruption in the epidermal barrier
- Is chronic: with (1) and (1) for most
- Associated with the Triad of (3) called “atopics”, will see elevated (1), often (1) bc has a large genetic component
A
Atopic Dermatitis (Eczema)
- Genetic and Environmental factors
- Exacerbations and Remissions for most
- Eczema, Allergies, Asthma, elevated IgE, often familial bc has large genetic component
24
Q
What is happening to cause Eczema to appear like this? What is this condition called?
A
Pt is scratching so much that it caused erosion, trauma and secondary bacterial infection - impetiginization
25
Atopic Dermatitis in Black Patients
(1) common
Pruritic Papules common in Black pts
26
Treatment for Ear Dermatitis
* May treat this with topical or corticosteroid otic solution—depending on how proximal sx are
* Hydrocortisone/acetic acid 3 drops Q4-6hrs
27
Periocular Dermatitis Treatment
(1)-(2)
**Topical calcineurin inhibitors (immunomodulators)**
* Pimecrolimus (Rx) – Elidel
* Tacrolimus ointment (Rx) - Protopic
*So much itching, doing it sleep, so probably need more long term tx*
28
Atopic Dermatitis (Eczema) Prevention
**Preventative measures are key!!**
* **(1) at least __ times/day & hydration**
* **(1) NOT soaps** ***(includes lauryl sulfate)***
* _____ frequent bathing
* NO hot baths/showers- _____ water only
* (2) especially after bathing *(no lotion)*
* Avoid products with fr\_\_\_\_\_, sc\_\_\_\_, or d\_\_\_ (includes soaps, lotions, detergents, scented candles)
* **Emollients at least 3 times/day & hydration**
* **Gentle cleansers NOT soaps** ***(includes lauryl sulfate)***
* Less frequent bathing
* NO hot baths/showers- lukewarm water only
* Ointments and thick creams especially after bathing *(no lotion)*
* Avoid products with fragrances, scents, or dyes (Includes: soaps, lotions, detergents, scented candles)
29
Eczema Prevention
Can also use topical Rx (1)
* _____ strength that will control symptoms
* Use in combo with Mupirocin or PO abx if (1) is suspected
Topical Corticosteroids
* Lowest strength that will control symptoms
* Use in combo with Mupirocin or PO abx if bacterial infection is suspected
30
Form of atopic dermatitis that occurs on hands, feet, or both
Characterized by **“tapioca-like vesicles”**
* Patients will report small, very itchy bumps
* In several weeks the vesicles resolve and skin appears, dry, erythematous, and scaly
Dyshidrotic Eczema
31
Dyshidrotic Eczema
Education and Prevention are Key
* **Wear \_\_\_\_\_** when doing dishes
* Avoid contact with harsh cleaning \_\_\_\_\_\_
* May be characterized by small, painful fissures → Liberal use of em\_\_\_\_\_\_ especially with (1) at bedtime
* **Wear gloves** when doing dishes
* Avoid contact with harsh cleaning chemicals
* May be characterized by small, painful fissures → Liberal use of emollients especially with (1) at bedtime
32
Dishydrotic Eczema DDx
**(3)**
Keep in mind secondary (1)
**allergic contact derm, herpetic whitlow, pustular psoriasis**
**secondary syphilis** *(not vesicles, no fluid)*
33
Chronic, _multisystem_ inflammatory dx, abnormal immune response leads to inflammation
*(breakdown of immune system causing hyperkeratizination of the skin, diff inflammatory cytokines/interleukins than atopic derm)*
* Characterized by **_well defined**_, circumscribed, erythematous _**plaques**_ with a _**classic silver or whitish scale_**
* Favors **_extensor_ surfaces** *(opposite of atopic derm)*
Psoriasis
* (bottom left 2 pics) Psoriasis on extensor surfaces *(most common elbows, knees, scalp, trunk)*, note the symmetry of plaques with silvery scale
* Bottom right pic: severe plaque psoriasis, note well defined borders, *often requires systemic treatment if \>30% BSA affected*
34
Psoriasis Risk Factors
* _____ predisposition
* Common in what ages?
* Dx at \_\_\_**-** ___ and __ - __ yo
* Men and women ____ effected
* Can occur in any ethnicity, however less prevalent in (2)
* Genetic predisposition
* Common in all ages
* Dx at 20-30 and 50-60 yo *(bimodal)*
* Men and women equally effected
* Can occur in any ethnicity, however less prevalent in Africans and Asians
35
Psoriasis Comorbidities
* **\_\_\_\_system** inflammatory disease
* 5% associated ar\_\_\_\_\_
* C\_ \_\_, D\_, (1) syndrome, H\_ \_*,* H\_ \_
* Also high incidence of (1) dt psychosocial impact of large plaques on skin
* **Multisystem** inflammatory disease
* ~5% associated arthritis
* CVD, DM, Metabolic syndrome, HTN, HLD
* Also high incidence of depression due to psychosocial impact of large plaques on skin
36
Psoriasis on Scalp
Treat with solutions, sh\_\_\_\_, o\_\_, and f\_\_\_\_
*These plaques can be extremely persistent and may require intralesional (1) to soften plaques and reduce localized inflammation, nbuvb, systemic medications*
solutions, shampoos, oils, foams
*These plaques can be extremely persistent and may require intralesional injections to soften plaques and reduce localized inflammation, nbuvb, systemic medications*
37
Psoriasis Guttate
Guttate =
* In addition to (1)**,** the following may trigger an attack of guttate psoriasis:
* (2) infections, including upper respiratory infections
* (1) to the skin, including cuts
* Some medicines, including those used to treat (1) and certain (1) conditions
* St\_\_\_\_, sun\_\_\_\_, excessive a\_\_\_\_\_ consumption
Guttate = tear drop
* In addition to **strep throat,** the following may trigger an attack of guttate psoriasis:
* Bacteria or viral infections, including upper respiratory infections
* Injury to the skin, including cuts
* Some medicines, including those used to treat malaria and certain heart conditions
* Stress, sunburn, excessive alcohol consumption
*All common triggers of psoriasis, pathogenesis not well known/understood*
38
Psoriasis of the Nails
Always assess the nails and ask about any hx of ____ pains if you suspect dx of psoriasis, will see ____ of nails
Always assess the nails and ask about any hx of joint pains if you suspect dx of psoriasis, will see pitting of nails
39
Psoriasis Treatment
**Mainstay (1)**
* Administration instructions: ___ daily dosing until (1) or up to __ weeks
* Tx varies according to s\_\_\_\_\_, l\_\_\_\_\_, and B\_ \_
* Helpful adjuncts (2)
* Atrophy not an issue until?
**Topical corticosteroids\***
* Administration instructions: twice daily dosing until sx respond or up to 4 weeks
* Tx varies according to severity, body location, and BSA
* Emollients and hydration, and thick creams especially after bathing
* Atrophy not an issue until you get past the plaque down to healthy skin
40
Psoriasis Other Agents
1. Topical (1) analog: Calcipotriene (Dovonox), Calcitrol (Vectical)
2. Intralesional ken\_\_\_\_ (ILK)
3. (1)- OTC and Rx, (1) (Tazorac - a class of retinoids)
4. UVB, PUVA = ***Psoralen + ultraviolet light A****. PUVA is a type of phototherapy used in treatment of psoriasis and other skin conditions*
5. (1) Agents - antibodies (Stelara, Humira, Enbril) - some have serious immunosuppressive **potential** side effects
6. Me\_\_\_\_\_\_, PO steroids
7. Ap\_\_\_\_\_ (Otezla)
1. Topical Vit D analog: Calcipotriene (Dovonox), Calcitrol (Vectical)
2. Intralesional kenalog (ILK)
3. Tar- OTC and Rx, Tazarotene (Tazorac - a class of retinoids)
4. UVB, PUVA = ***Psoralen + ultraviolet light A****. PUVA is a type of phototherapy used in treatment of psoriasis and other skin conditions*
5. Biologic Agents - antibodies (Stelara, Humira, Enbril) - some have serious immunosuppressive **potential** side effects
6. Methotrexate *(old school)*, PO steroids *(avoid, but can offer short term relief while waiting for derm consult)*
7. Apremilast (Otezla)
41
Psoriatic Arthritis
Rash usually ____ arthritis
(Arthritis precedes rash in 15-20% of cases)
* Age onset \_\_-\_\_ yo with _____ predisposition
* Mild to highly destructive - \_\_\_\_ful & de\_\_\_\_\_
* Can affect any joints (f\_\_\_\_, sp\_\_\_, k\_\_\_\_)
* Does not \_\_\_\_\_\_w/extent of skin - sometimes psoriasis never manifests
* ____ involvement sometimes higher incidence
* Refer to **(1) or (1) to start _____ therapies**
Rash *usually* precedes arthritis
(Arthritis precedes rash in 15-20% of cases)
* Age onset 30-50 yo with genetic predisposition
* Mild to highly destructive - painful & debilitating
* Can affect any joints (fingers, spine, knees)
* Does not correlate w/extent of skin - sometimes psoriasis never manifests
* Nail involvement sometimes higher incidence
* Refer to **dermatology or rheumatology to start biologic therapies** *(refer ASAP bc helps reduce debilitating disease of arthritis)*
42
Healthy 22 y.o. with tender lesion on great toe for 9 months, increasing size x several weeks. What is the most likely diagnosis?
1. Tinea pedis (athletes foot)
2. Verruca plantaris (plantar wart)
3. Common callus or corn
4. Squamous cell carcinoma (verrucous carcinoma)
1. Tinea pedis (athletes foot)
2. **Verruca plantaris (plantar wart)**
3. Common callus or corn
4. Squamous cell carcinoma (verrucous carcinoma)
43
55 yo male presents for rash on abdomen, back, elbows, and knees that appeared 2 months ago. PMH sig for HTN. Reports occasional itch, denies pain or burning. Admits to occasional swelling in L knee, which is not relieved with ibuprofen. He reports recent weight gain and significant stress due to losing his job.
* You suspect the patient has psoriasis. Which of the following would **_not_** be an appropriate intervention
1. Referral to rheumatology
2. Prescribing Clobetasol twice daily
3. Ordering a fasting lipid panel and doing EKG
4. Prescribing Ketoconazole cream twice daily
1. Referral to rheumatology
2. Prescribing Clobetasol twice daily
3. Ordering a fasting lipid panel and doing EKG
4. **Prescribing Ketoconazole cream twice daily**
44
Acne
* Typically starts at \_\_\_\_\_
* \_\_% of adolescents
* Occurs in 20% of (1) around 3-4 wks
* Can occur as new onset in (1) less commonly
* Dt increased (1) hormone
* Typically starts at puberty
* 80% of adolescents
* Occurs in 20% of newborns around 3-4 wks
* Can occur as new-onset in adults less commonly
* Increased androgens
45
Acne Patho
1. Starts with increased (1)
2. Colonization of (1)
3. Increased proliferation and sebum creates (1) of sebaceous unit then (1)
4. (1) develops as a white or black head, then mixing with bacteria can create an (1) response = a PIMPLE
1. Starts with increased sebum production in our pilosebaceous unit
2. Colonization of P. acnes
3. Increased proliferation and sebum creates widening of sebaceous unit then clogging
4. Comedones develop as a white or black head, then mixing with bacteria can create an inflammatory response = a PIMPLE
46
Comedonal Acne (Noninflammatory)
* **(1)** open comedones
* Due to (1) NOT dirt, combo of (3) occludes the pilosebaceous unit
* **(1)** closed comedones
* distended follicle, but ____ stays intact
* **"Black heads"** open comedones
* Due to oxidized lipid NOT dirt, combo of keratin, cornified cells, and oil occludes the pilosebaceous unit
* **“White heads”** closed comedones
* distended follicle, but epidermis stays intact
47
Cystic Acne (Inflammatory)
*Proprionobacterium Acnes → activation of (1) and (1) cells → \_\_\_\_\_*
* Proprionobacterium Acnes → activation of cytokines and immune cells → inflammation*
* A comedo may become progressively larger and eventually be gigantic. In time, the ever-expanding plug of cornified cells causes the wall of an infundibulum to become so thin that eventually it is breached, spewing into the dermis cornified cells, sebaceous secretion, and microorganisms*
48
Treatment for Comedonal Acne
**(1)** **(Retin A)** - active form of vitamin A
1. Dry skin - use ___ (0.1, 0.05, 0.025%)
2. Oily skin - use ___ (0,025, 0.01%)
3. Start dosage and frequency \_\_\_
4. Admin instructions =
**(1)** **(BPO)** 2.5%, 5%, 10%
1. When can you use a higher percentage?
**(1)** Often in **combo with BPO**
1. **(1) Rx** 1% most effective OR **(1) Rx 3%**
**Tretinoin (Retin A)** - active form of vitamin A
1. Dry skin - use cream (0.1, 0.05, 0.025%)
2. Oily skin - use gels (0,025, 0.01%)
3. Start at Low dose and frequency (2, 3, 4 nights/week)
4. ONLY APPLY PEA SIZE TO ENTIRE FACE, RETINOIDS NOT SPOT TREATMENTS/avoid oil containing products
**Benzoyl Peroxide** **(BPO)** 2.5%, 5%, 10%
1. Can use a higher percentage if no hx of sensitive skin, eczema, allergy, and if acne on chest or back
**Topical Abx** Often in **combo with BPO**
1. **Clindamycin 1%** most effective OR **Erythromycin 3%**
49
Treatment for Inflammatory Acne
**(1)** helps reduce inflammation and P. acnes
**Rx (1) or (1)** 50-100mg qd-bid
**SE (3)**
(1) pregnancy category D, enters breast milk
Never give \< __ yo
*Often will not see effects up to (1), and often course is for (1) long → if no improvement refer to derm to consider isotretinoin*
**Systemic antibiotics** helps reduce inflammation and P. acnes
## Footnote
**Minocycline or Doxcycline** 50-100mg qd-bid
**SE: GI, photosensitivity** (doxy), **HA/dizziness** (mino)
TCN pregnancy category D, enters breast milk
Never give \<8 yo
*Often will not see effects up to 10d, and often course is for 3m long → if no improvement refer to derm to consider isotretinoin*
50
Inflammatory Acne Treatment cont.
* _____ tx alone if mild or moderate
* (1) if pustules, cysts, large area, and is moderate to severe
* Topical tx alone if mild or moderate
* PO Abx if pustules, cysts, large area, and is moderate to severe
* Always have a plan to discontinue PO Abx; Explain resistance and importance of pregnancy prevention*
* Biggest concern in latin/black post inflammatory hyperpigmentation (dark spots) - retinoids and sunscreen can help the PIH get worse*
51
Acne Pearls
1. Tx depends on t\_\_\_ and s\_\_\_\_
2. All treatments require consistent use for ~\_\_ weeks before determining if effective
3. Severe acne should be (1)
4. Many acne products naturally result in (2)
1. Use non-\_\_\_\_ lotions to manage dryness (ie ____ AM/PM)
2. May need to decrease fr\_\_\_/po\_\_\_\_ of tx
3. ONLY APPLY ___ SIZE FOR ENTIRE FACE
5. (1) → decreases oil production (tricyclen, desogen, yaz)
6. NO Rx (2) in pregnancy, (2) are safe
1. Tx depends on **type and severity**
2. All treatments require consistent use for **~12 weeks** before determining if effective
3. **Severe acne should be referred to derm**
4. Many acne products naturally result in **dryness and irritation**
1. Use non-comedogenic lotions to manage dryness (ie CeraVe AM/PM)
2. May need to decrease frequency/potency of tx
3. ONLY APPLY PEA SIZE FOR ENTIRE FACE
5. Low androgen oral contraceptives → decreases oil production (tricyclen, desogen, yaz)
6. NO Rx retinoids or tetracyclines in pregnancy, clinda lotion and azaleic acid are safe
52
Nodulocystic Acne
* Can result in permanent scarring so important to (1) ASAP
* May need Rx (1) - KEY IS EARLY TX TO PREVENT PERMANENT SCARRING!
* Only providers who have gone through specialized ______ can prescribe
* ______ is major issue w its use - severe teratogen
* Can result in permanent scarring so important to refer to derm ASAP
* May need Rx Isotretinoin (Accutaine) - KEY IS EARLY TX TO PREVENT PERMANENT SCARRING!
* Only providers who have gone through specialized training can prescribe
* Contraception is major issue w its use - severe teratogen
53
16 yo female presents for treatment of mild-moderate, comedonal acne, mainly non-inflammatory only on the face. She is really distraught over the appearance of her skin because she gets made fun of in school. She has no sig PMH and NKDA. She is requesting a pill to make it go away quickly Your best treatment choice is
1. Prescribe Clindamycin 1% lotion to use in combo with an OTC BP wash twice daily
2. Start her on oral contraceptives
3. Prescribe Doxy 100mg twice daily
4. Refer to derm
5. Start tretinoin 0.1% cream every night
1. **Prescribe Clindamycin 1% lotion to use in combo with an OTC BP wash twice daily**
2. Start her on oral contraceptives
3. Prescribe Doxy 100mg twice daily
4. Refer to derm
5. Start tretinoin 0.1% cream every night
*reserving oral abx for inflammatory, would also give tretinoin in conjunction but wrong answer bc 0.1% is the strongest concentration, would burn her face*
54
4 Types of Rosacea
## Footnote
**(1)** flushing w or w/o stinging or burning
**(1)** (most common)
**(1)** overgrowth of affected sebaceous glands, large, bulbous erythematous nose/thickening - almost exclusively in men
**(1)** blepharitis and conjunctivitis
**Erythematotelangiectatic**
**Papulopustular**
**Phymatous**
**Occasionally Ocular**
55
Chronic Inflammatory, Acneiform disorder typically of mid-aged and older adults
Rosacea
56
Rosacea Prevalence
* Men __ Women
* Greatest incidence in the what ethnicity?
* Affects all ethnicities, buy may be more difficult to diagnose in patients with skin of \_\_\_\_\_\_
* Affects men and women equally
* Greatest incidence in the Irish
* Affects all ethnicities, buy may be more difficult to diagnose in patients with skin of color
57
Rosacea Treatment
**1st line**
* (1) QD dosing
* (2) BID dosing
**If nodular or pustular?**
**Topical Metronidazole**
* Gel QD dosing
* Cream or Lotion BID dosing
**Oral abx Doxy or Mino**
58
Rosacea Treatment Other Topical Tx
* B\_ \_, Topical abx (2)
* (1) a newer tx that kills demodex mite - *part of patho of rosacea*
* (1) (Finacea Gel)
* S\_\_\_\_/S\_\_\_\_ (creams or washes)
* BPO, Topical Clinda or Erythromycin
* Ivermectin 1% (Soolantra)
* Azaleic Acid
* Sulfacetamide/Sulfur
59
Rosacea Education
Avoid (1) when possible
* S\_\_\_ exposure, T\_\_\_\_ extremes, St\_\_\_\_\_
* A\_\_\_\_\_ *(especially (1))*, (2) foods or drinks
* Rec a _____ skin care regimen
Avoid triggers when possible
* Sun exposure, Temp extremes, Stress
* Alcohol (*especially red wine)*, spicy or hot foods or drinks
* Rec a gentle skin care regimen
60
Rosacea DDx
* (1) but has to have comedones
* **(1)** *(cousin of rosacea, may hae similar triggers but fluorinated toothpastes, and wearing masks during covid, i usually do a sulfa wash and elidel)*
* (1) autoimmune disorder
* (1) dermatitis
* Acne
* **Perioral Dermatitis**
* SLE
* Seborrheic Dermatitis
61
Chronic Autoimmune, Multisystem inflammatory connective tissue disease
Lupus Erythematosus
62
Lupus Prevalence
* \> in what gender (1), \_\_- __ yo
* F:M \_\_\_: \_\_\_
* Any age can be affected (1) has increased mortality
* Female 15-35yo
* F:M 10:1
* Any age can be affected, kids have increased mortality
63
Lupus Characteristics
* R\_\_\_\_ and F\_\_\_\_ common
* Observe for **(2) rashes** with systemic symptoms
* S/S = F\_\_\_\_, My\_\_\_\_, (1) pain, W\_\_\_\_
* **\_\_\_\_\_sensitivity** often reported
* Remissions and Flairs common
* **Malar (Butterfly) Rash, Discoid Rash**
* Fatigue, Myalgias, Joint pain, Weakness
* **Photosensitivity**
64
Malar Rash of Lupus
What makes it different from other skin conditions?
*Found in % of pts, no ____ like in rosacea*
**Spares the Nasolabial Folds**
*20% of pts, no telangiectasia*
65
Discoid Rash of Lupus
Only found in 20% of pts with SLE
**Discoid Lupus Erythematous** typically presents in the __ or __ decade of life
If patient presents just with discoid rash, no systemic symptoms, do they have lupus?
**DLE** 4th or 5th decade of life
*Can have discoid rash and NO SLE*
66
Pruritic rash on torso for a couple weeks; annular lesion with scaly, erythematous border, central clearing. Asx otherwise. What is the most likely diagnosis?
1. Tinea corporis
2. Pityriasis rosea
3. Discoud lupus
4. Erythema migrans
1. **Tinea corporis**
2. Pityriasis rosea
3. Discoud lupus
4. Erythema migrans
