LECTURES 69 & 70 & 71 - dermatology Flashcards
(138 cards)
1
Q
List common features of Xerosis (dry skin)
A
Fall & winter
Feet, lower legs
Hands, elbows, face
Rough, dry, scales, cracks
Itching is common sx
2
Q
Describe dermatitis
A
Inflammatory process of the upper 2 layers of skin
Classifications:
Acute
Sub-acute
Chronic
3
Q
Describe acne
A
A chronic inflammatory disease of the sebaceous glands & hair follicles of the skin characterized by comedones, papules, and pustules
Classes: inflammatory & non-inflammatory
4
Q
Describe the pt population affected by acne
A
- Affects 90% of the adolescent population
(corresponds to increased androgen production) - 80% of pts with acne are between 12-30 YO
- Males more severe during puberty & females during adulthood
5
Q
Describe the presentation of non-inflammatory acne
A
Whiteheads & Blackheads
6
Q
Describe the presentation of inflammatory acne
A
Papules, Pustules, Ruptured Contents
7
Q
Describe rosacea
A
Common, chronic, progressive inflammatory dermatosis based upon vascular instability
- Persists for years, with periods of exacerbation & remission
- Primarily affects the central part of the face
8
Q
Describe characteristics of rosacea
A
- Facial flushing / blushing
- Facial erythema
- Papules
- Pustules
- Telangiectasia
9
Q
List the subtypes of rosacea
A
Telangiectatic
Papulopustular
Phymatous
Ocular
10
Q
Describe psoriasis
A
Chronic autoimmune inflammatory skin disorder:
- Usually a series of exacerbations / remissions
- T-lymphocyte mediated
- Keratinocyte proliferation
- Rapid skin growth - 7x faster than normal
11
Q
Describe the clinical presentation of psoriasis
A
Thickened, red patches covered by silvery-white scales
12
Q
List the classifications of psoriasis
A
Limited
Generalized (Moderate - Severe)
13
Q
List advantages of using ointment as a vehicle
A
- best for hydration
- best for drug delivery
- removes scales
14
Q
List disadvantages of using ointment as a vehicle
A
- greasy
- low pt acceptance
- not ideal for hairy areas
15
Q
List advantages of using cream as a vehicle
A
- good for hydration
- good for drug delivery
- can apply to most areas (hairy, groin, face)
- high pt acceptance
16
Q
List disadvantages of using cream as a vehicle
A
none in notes
17
Q
List advantages of using lotion as a vehicle
A
- watered down creams
- easy to apply
- good pt acceptance
18
Q
List disadvantages of using lotion as a vehicle
A
- requires freq. applications
- not ideal for very dry skin
19
Q
List advantages of using gel as a vehicle
A
- excellent for EtOH soluble drugs
- can apply to most areas (hairy, groin, face)
- high pt acceptance (non-greasy)
20
Q
List disadvantages of using gel as a vehicle
A
can be drying
21
Q
List advantages of using Solution, Foam, Spray as a vehicle
A
- can apply to most areas
- easy to apply to hairy & groin areas
- not ideal for drug delivery
22
Q
List disadvantages of using Solution, Foam, Spray as a vehicle
A
- can be drying
- not ideal for hydration
- requires freq. applications
23
Q
List what is considered when choosing the best base (vehicle) for medication delivery
A
Desired effect from base:
– Dry the skin vs. moisturize
– Water-resistant vs. washes right off
Area of application
Pt acceptability
The nature of the incorporated medication:
– bioavailability
– stability
– compatibility
24
Q
When should pts be referred to MD?
A
- Multiple or extensive burns
- Human or animal bites
- Multiple or extensive cuts, bruises, abrasions
- Rash that is extensive, weeping, or infected
- Tumors or growths
- Yellow skin
- Deep infection (cellulitis)
- Large blisters of unknown origins
- Exposed deep tissue, muscle, or bone
25
List risk factors for Xerosis (dry skin)
Elderly:
-- Decreased activity of sweat & sebaceous glands
-- Very warm, dry environments
Frequent bathing
26
List features of acute dermatitis
Red patches / plagues
Pebbly surface / blisters
Itching is intense
27
List examples of acute dermatitis
- contact dermatitis (irritant vs. allergic)
- poison ivy
28
Describe acute contact dermatitis
- acute IRRITANT dermatitis
- Non-immunologic reaction to frequent contact with everyday substances
- More common than allergic
- Reaction w/in a few hours
- Common irritants (Metals, Cosmetics, Adhesives)
29
List features of sub-acute dermatitis
- Dry
- Less red
- Crusting, oozing
- Mild thickening
- Itching is common but less intense
30
List examples of sub-acute dermatitis
atopic dermatitis
eczema
31
Describe features of chronic dermatitis
- Epidermal thickening
- Exaggerated skin markings
- Excoriations, fissures, scaling
- Lichenification
- Less itching
32
List examples of chronic dermatitis
- Stasis dermatitis
- Any long standing acute / sub-acute dermatitis
- Irritation & trauma worsen itching
33
List symptoms of atopic dermatitis
(type of sub-acute dermatitis)
- Pruritus
- Symmetric red papules or plaques
- Scaling excoriations
- Overall dryness of skin
- Redness & inflammation
- Hx of allergic disease
- Risk of 2nd infection
34
List potential triggers of atopic dermatitis
Allergens
Chemicals
Bathing
Detergents
Soaps
Smoke
Dust
Infections
35
Describe the "atopic march"
- a triad of diseases that are typically associated: atopic dermatitis, asthma, allergic rhinitis
- atopic dermatitis is often the first disease of atopic / allergic triad to be observed
**50-75% also develop another disease in triad**
36
Describe the infant-specific presentation of atopic dermatitis
- Red, papular skin rash on cheeks & skin
- Lesions often crust over time
- Lesions later appear on neck, truck & groin
- Itching often results in irritability
37
Describe the child-specific presentation of atopic dermatitis
- Face, neck, flexural crease of arms & legs
- Skin often appears dry, flaky rough, cracked, and may bleed from scratching
- Sleep disturbance is common
- Greater risk of secondary skin infections
38
Describe the adult-specific presentation of atopic dermatitis
- Hands & neck
- Flexor surfaces of the arms & legs
- Excoriation & lichenification from chronic scratching
- Intense itching, sleep disturbances, altered QOL, depression
39
Define "comedone"
hair follicle plugged with sebum, keratin & dead skin
40
Explain the pathophysiology of acne
- Keratinous obstruction of sebaceous follicle outlet
- Traps sebum (comedones)
- Bacterial colonization in trapped sebum
41
Explain bacterial colonization in acne
- **Propionibacterium acnes** naturally colonize the skin & sebaceous glands
- Proliferates in sebum environment
- Bacteria converts TG → FFA which irritates local cell resulting in inflammation
42
List exacerbating factors of acne
- Oil-based cosmetics
- Emotional stress
- Irritation / Physical pressure
43
List drugs that may cause acne
- Androgenic steroids
- Corticosteroids
- Lithium
- Anti-epileptics (phenytoin)
- Tuberculosis drugs
- Oral contraceptives
44
Describe secondary lesions from acne
Excoriations
Erythematous macules
Hyperpigmented macules
Scars
45
Describe populations affected by rosacea
Ages of 25-70 years
People with fair complexions
Women > men
46
List potential trigger factors of rosacea
- Foods
- Temperature / sun
- Weather
- Beverages
- Medical conditions
- Emotional influences
- Physical exertion
- Skin products
- Drugs
47
List drugs that could potentially trigger rosacea
- Vasodilators
- Topical corticosteroids
- Nicotinic acid
- ACE inhibitors
- Calcium channel blockers
- Statins
48
Describe Telangiectatic rosacea
Visibility dilated blood vessels
Very red skin
49
Describe Papulopustular rosacea
Resembles acne
Often referred to as “adult acne”
50
Describe Phymatous rosacea
Enlarges sebaceous glands
Especially the nose
More common in males
51
Describe Ocular rosacea
Watery eyes
Bloodshot eyes
52
Describe "limited" psoriasis
5% body surface area (BSA)
53
Describe "generalized moderate" psoriasis
5% - 10% BSA
54
Describe "generalized severe" psoriasis
10% BSA
55
List potential triggers of psoriasis
- Stress
- Environment (cold)
- Injury
- Infection
- Smoking
- Drugs (NSAIDs, ACE, lithium)
- Diet
56
List treatment options for Xerosis (dry skin)
non-pharm: alter bathing habits (rule of 3)
pharm: emollients, agents for itching
57
Describe how emollients are used for the treatment of Xerosis (dry skin)
First line for itching
Restores barrier & skin function
58
List emollient options for treatment of Xerosis (dry skin)
Vaseline, Aquaphor, Cetaphil, Nivea, Keri, Lubriderm, AmLactin, Eucerin, CeraVe
59
List agents that can be used to treat itching associated with Xerosis (dry skin)
menthol & camphor (1/2 - 1%)
pramoxine (1%)
aluminum acetate (0.2%)
hydrocortisone (0.5% & 1%)
60
Explain how menthol & camphor treats Xerosis (dry skin)
Creates a sensation of cooling
61
Explain how pramoxine treats Xerosis (dry skin)
Local anesthetic
62
Explain how aluminum acetate treats Xerosis (dry skin)
Alter C-fiber transmission
63
Explain how hydrocortisone treats Xerosis (dry skin)
anti-inflammatory
64
Explain how bathing habits should be altered for the treatment of Xerosis (dry skin)
Rule of "3"
- Tub bath or shower NO MORE than 3x / week
- Tepid water (3-5 degree above body temp)
- Bathe for 3-5 minutes
- Pat dry
- Apply copious amount of emollients within 3 minutes
- Apply emollients at least 3x / day
65
Describe the general treatment principles for dermatitis
Stop the itching-scratch cycle
Ability to carry out tx
66
What are the treatment options for acute dermatitis?
corticosteroids
systemic therapy - antihistamines
67
What is the MOA of topical corticosteroids used for acute dermatitis?
Anti-inflammatory
Anti-mitotic (inhibits cell proliferation)
Immunosuppressive
68
How long should topical corticosteroids be used to treat acute dermatitis
Always treat minimum 1 day beyond resolution
69
What is the dosing regimen for topical corticosteroids used for tx of acute dermatitis?
Apply BID-QID x 3-14 days
**avoid dose packs**
70
What is the DOC (topical corticosteroid) for the treatment of acute dermatitis & preferred dosing regimen?
prednisone (40-60 mg/day)
-- taper q3 days
-- min. 10-14 days of tx
71
List options for systemic therapy tx of acute dermatitis
non-sedating antihistamines
(loratadine, desloratadine, fexofenadine)
sedating antihistamines
(diphenhydramine, cetirizine, hydroxyzine, doxepin (Rx))
72
List non-pharm treatment options for atopic dermatitis
- Lukewarm / tepid baths
- Emollients
- Eliminate irritants, modify environments, avoid triggers
- Trim fingernails, non-irritating clothing
73
List topical therapy options for the treatment of atopic dermatitis
- Topical corticosteroids (TCS)
- Topical calcineurin inhibitor therapy
- Topical JAK inhibitor
**strength/duration of use based on severity**
74
List systemic therapy options for the treatment of atopic dermatitis
- Phototherapy
- Oral immunosuppressant therapy
- Oral JAK inhibitors
- Injectable biologic agents
75
What is the best therapy option for acute flares of atopic dermatitis?
**moderate-severe**
Medium-potency TCS BID for up to 3 days beyond clearance of lesions
76
Explain the recommended maintenance therapy for moderate-severe atopic dermatitis
Basic measures + daily application of low-potency TCS
OR
2-3x/week application of TCS / topical anti-inflammatory agent
(written action plan !!)
77
What are treatment options for refractory atopic dermatitis (atopic derm. that is resistant to topical agents)
Phototherapy or oral immunosuppressive therapy
78
What are treatment options for atopic dermatitis that is responding inadequately to all therapies?
Consider emerging biologic agents
79
List prevention options for dermatitis due to direct / indirect contact with Poison Ivy
Ivy-Block – protectant & barrier
Re-apply q4h
Wash skin & nails w/in 10 minutes (clothing too)
80
List treatment options for a limited rash caused by poison ivy
- Remove source
- Calamine lotion
- Topical antihistamines
- Topical / Oral corticosteroids
81
List the goals of therapy for acne
- Long-term control
- Relieve discomfort
- Improve skin appearance
- Minimize psychological stress
- Prevent scars
82
What should all patient with acne be counseled on?
- Follow a regular skin cleansing regimen using a mild facial soap BID
- Minimize the use of products that cause irritation stinging (aftershave, alcohol-based cleansers)
- Use tepid, NOT HOT, water to clean affected areas
- No quick fix → weeks - months
83
Explain the MOA of acne therapy
Antimicrobial
Anti-inflammatory
Decrease sebum production
Keratolytic
Comedolytic
84
Define "keratolytic" & give examples of keratolytic compounds
Compounds that break down the outer layers of skin, decrease the thickness, promote sloughing
Examples:
Salicylic acid, Urea, Alpha-hydroxy acids
85
Define "comedolytic" & give examples of keratolytic compounds
A product or medication that inhibits the formation of comedones
Examples:
Tretinoin, Adapalene, Azelaic acid
86
List combination products available for acne
Clindamycin + Benzoyl Peroxide → Duac
Adapalene + Benzoyl Peroxide → Epiduo Forte
87
Describe the MOA of oral antibiotics for acne
Decreases bacterial & inflammation
(weeks to see improvement)
Most effective when inflammation is present
88
List potential risks of using oral antibiotics for acne
allergy, photosensitivity, GI upset, thrush
Risk of RESISTANCE (limit tx to 6-8 weeks)
89
How can oral antibiotics be used for long-term treatment?
After inflammation is controlled D/C & treat with other topical methods for long-term tx
90
List examples of oral antibiotics that can be used for the tx of acne
Minocycline, Doxycycline, Erythromycin, Azithromycin, TMP/SMX
91
List treatment options for oral-androgen therapy for the tx of acne
Hormone tx:
Low-dose OCs
Spironolactone 100-150 mg/day
Clascoterone 1% cream (topical)
92
Who are the best candidates for hormone therapy for the tx of acne & why?
Ideal for females whose acne flares during menstrual cycle:
Decreases androgen production, which reduces sebum & comedone formation
93
What is the best tx option for SEVERE acne?
Isotretinoin
94
List the indications for the use of Isotretinoin
- Severe acne
- When pts pave failed other treatments
- When it relapses soon after d/c other therapies
95
What is the MOA for isotretinoin?
Reduces sebum production & shrinks sebaceous glands
96
What are some counseling points for taking Isotretinoin?
take with food
acne will get worse before it gets better
97
List general counseling points for Isotretinoin
- Avoid pregnancy / proper use of contraceptives
- Adverse effects
- Do not take vit. A supplements
- Use moisturizer, lip balm, artificial tears
- Use a sunscreen
- Take with food
- iPledge program
98
List treatment options for complications associated with acne
Dermabrasion
Chemical peels (70% glycolic acid)
Laser resurfacing
99
List lifestyle modifications to treat rosacea
- Avoid triggers known to exacerbate
- Avoid excessive exposure to the sun
- Use mild soaps & cleansers
- Stress adherence to topical meds
- Topical meds should be allowed to penetrate the skin for 5-10 min before applying makeup
100
List the treatment for persistent facial erythema due to telangiectatic rosacea
Mirvasco 0.33% Gel (brimonidine)
101
List the treatment of choice for mild rosacea
Topical antibiotics:
Metronidazole 1% (cream, gel, lotion)
Clindamycin, Sulfacetamide & Sulfur
**also avoid triggers**
102
What is the second treatment option for mild rosacea
Topical retinoids:
- Azelaic Acid (Finacea Gel 15%)
**other retinoids can be used as alternatives**
103
Describe the MOA of topical retinoids
Antibacterial, comedolytic & anti-inflammatory effects
Less acidic / better absorbed than acne formulation
104
List treatment options for moderate rosacea
oral antibiotics
topical retinoids
105
List oral antibiotics that can be used for the treatment of moderate rosacea
Doxycycline 50-100 mg daily or BID
Minocycline 50-100 mg BID
Used alone -OR- in combo with topicals
Dosing varies depending on severity
106
List treatment options for severe rosacea
- oral isotretinoin
- tretinoin
- laser treatments
107
Describe how oral Isotretinoin can be used to treat rosacea & any side effects
Use only for most severe cases
Weight risks vs. potential benefits
108
Describe how tretinoin can be used to treat rosacea & any side effects
Used for more severe cases
May worsen erythema & telangiectasias
109
Describe how laser treatments can be used to treat rosacea & any side effects
- Used to remove blood vessels and reduce excessive redness
- A minimum of 3 treatments is usually required
- May also be used in more severe cases to retard build up or remove unwanted tissue and reshape the nose
110
List treatment options for ocular rosacea
Ophthalmic drops
111
List the goals of therapy for psoriasis
- Decrease symptoms
- Decrease % of BSA affected
- Improve QOL
- Reduce inflammation & slow down rapid skin cell division
- Achieve clearing of lesions
- Use topical therapy over systemic therapy whenever possible
- Prolong periods between exacerbations
112
List general measures that can be taken to prevent / treat psoriasis
Sun
Baths
Emollients
Keratolytics (salicylic acid 2%)
113
What is the general approach for treatment of psoriasis
topical therapy
-- Most effective when used to treat localized plaque psoriasis covering < 20% BSA
114
Define tachyphylaxis
Development of tolerance to the anti-inflammatory activity with repeated use
115
List first-line therapy options for the treatment of psoriasis
- Emollients
(used for all pts with psoriasis)
- **Corticosteroids**
- Calcipotriene / Calcitriol
- Cort + Vit D analog
- Cort + Tazorotene
- Calcineurin inhibitor
116
Describe TCS for the treatment of psoriasis
- decreases scaling, erythema, pruritis
- High / Very High potency ointment preferred for scaly lesions, after initial tx, mid-potency products used
(avoid using super-potent agents for > 2 weeks)
**no more than 50 g/week**
**risk of tachyphylaxis**
117
Explain how Calcipotriene / Calcitriol can be used to treat psoriasis
- Inhibit proliferation of lesions
- Potency equiv. to mid potency corts
- Well tolerated, no tachyphylaxis
118
Give examples of Cort + Vit D analogs that can be used to treat psoriasis
Calcipotriene + Betamethasone (Taclonex)
Ointment + Topical Suspension
119
When should calcineurin inhibitors be considered for treatment instead of corticosteroids?
For areas not suitable for corts
(face & flexures)
120
Describe UV phototherapy for the treatment of psoriasis
Targeted phototherapy for limited & resistant plaques (immunomodulatory effect)
used for pts with mild-mod disease who do not completely respond to topical agents
used in combo with systemic / biologic x for pts with severe disease
**overall role has increased in recent years**
121
Describe UVA vs. NB-UVB phototherapy
UVA: Penetrates ticker lesion better than UVB
NB-UVB: Tx of choice for initial therapy - thinner lesions
122
Describe PUVA (psoralen + UVA) for the treatment of psoriasis
Methoxsalen:
0.6 - 0.8 mg/kg PO 2 hours before UVA tx
2-3 tx/week
Photosensitizer
123
List potential risks of UV phototherapy
skin aging, skin cancer (squamous cell)
124
What is first-line therapy for SEVERE psoriasis?
Biologic therapy:
- TNF inhibitors
- T-cell activation inhibitors
125
List key aspects of biologic therapy used to treat psoriasis
- Very expensive
- PAs
- Injection site discomfort most common SE
- Monitor pts for s/sx of infections/bleeding
- Many pts will require supplemental topical therapies
- Avoid use of LIVE virus vaccines
126
Describe 2nd line therapy options for SEVERE psoriasis
Oral retinoids, Cyclosporine, Methotrexate
127
What is the follow-up timeframe for acne treatment?
2-6 month follow-up to determine if tx regimen has been successful
128
How does occlusion affect penetration?
Occlusion enhances penetration
129
How does the type of vehicle used affect corticosteroid treatment?
Vehicle impacts delivery && potency of corticosteroids
130
What is the corticosteroid potency classification system based on / correspond to?
anti-inflammatory activity & vasoconstrictive potency
131
Give examples of very high potency (class 1) corticosteroids
- Halbetasol propionate (Ultravate)
- Clobestason propionate (Cormax, Temovate)
- Betamethasone dipropionate Oint (Diprolene)
132
List some key points about very high potency (class 1) & high potency (class 2) corticosteroids
- Used for very severe lesions & on thickened skin when maximum penetration is needed
- DO NOT USE ON FACE
- Avoid super-potent agents for > 2 weeks
- Limit to no more than 50 g/week
133
Give examples of high potency (class 2) corticosteroids
- Fluocinolide Cr, Gel, Oint (Lidex)
- Betamethasone dipropionate Cr (Diprolene)
134
Give examples of mid potency (classes 3-5) corticosteroids
- Betamethasone valerate (Valisone)
- Triamcinolone acetonide (Kenalog)
- Memetasone furoate (Elocon)
- Betamethasone dipropionate lotion (Diprolene)
135
Give examples of low potency (classes 6-7) corticosteroids
- Hydrocortisone (Cortaid)
- Desonide (Desonate)
136
List some key points about mid potency (classes 3-5) corticosteroids
- Used on most skin surfaces for exacerbations
- Moderate anti-inflammatory effect
- Safer for longer usage than high potency
137
List some key points about low potency (classes 6-7) corticosteroids
- Use on face, groin, genitals, axilla
- Mild anti-inflammatory effect
- Safest for long-term maintenance use
138
What is the equivalent of 1 FTU (Finger Tip Unit)?
½ g of cream / ointment
