Rosacea and Scaly Dermatoses Flashcards

Question

Dandruff Treatment Goals

Answer 1

Reduce epidermal turnover rate of scalp skin Minimize the cosmetic embarrassment of visible scaling Minimize itching

Answer 2

Mild presentation: -Non-medicated shampoo (Daily or every other day) Moderate to severe presentation : - OTC medicated shampoos (pyrithione zinc or selenium sulfide) - Leave on for 3 to 5 minutes - Rinse well with water - Use 2 – 3 times weekly for 2 to 3 weeks, then once weekly for control

Answer 3

Chronic inflammatory disorder occurring in areas of sebaceous gland activity Chronic condition with no specific cure Neither harmful nor contagious Affects 3 – 5% of adults, men more than women Ages 18 to 40 years

Answer 4

Greasy or dry scaling of the scalp, sometimes a "cradle cap" Mildly scaling eczematous patches on the face at typical locations (eyebrows, nasolabial creases, "sideburn” area)often with itch and stinging Itch and inflammation of the ear canal Blepharitis (eyelid infection) Well-demarcated eczematous patches - --on mid-upper trunk - --at intertrigo areas (skin folds or juxtaposed surfaces of skin)

Answer 5

- Malassezia (a yeast – like fungus) grows in the sebum along with bacteria - Hormones - Physical stress, fatigue, travel - Zinc deficiency - Obesity - Season Change (worse in cold weather) - HIV infection - Parkinsonism

Answer 6

Reduce inflammation and epidermal turnover rate Minimize or eliminate visible erythema and scaling

Answer 7

- Loosen and remove scales and crusts - Inhibit yeast colonization (Malassezia) - Reduce erythema and itching - Avoid perfumes, aftershave, ointments, soaps - Control secondary infections

Answer 8

The scales can be softened with: - -Cream containing salicylic acid and sulphur - -Wetting and washing Seborrhoeic skin should be washed more often than twice daily

Answer 9

Washing the scalp - -Ketoconazole shampoo [first line] or - -Selenium sulfide shampoo [second line] Shampoo scalp with medicated shampoo product daily for a week, then 2-3 times a week leave shampoo on hair, scalp and affected areas for 5 minutes; then rinse may repeat After 4 weeks (if see improvement) may reduce frequency of medicated shampoo to once weekly If worsens after 1 to 2 weeks on OTC meds/shampoo, refer to physician Topical treatment with Imidazole derivative creams Sometimes ultraviolet light therapy

Answer 10

Corticosteroid lotion for the scalp (from mild to potent) Corticosteroid creams for other parts of the body (from mild to potent) Moisturizing emollients after washing Ketoconazole shampoo and corticosteroid lotion must often be combined in therapy-resistant cases.

Answer 11

“Cradle cap” Remove scaling on scalp: - Massage scalp with baby oil - Use non-medicated shampoo - Soft bristle brush -For severe cases: Salicylic Acid 3 – 5 % in olive oil or water soluble base On face – wash with mild soap or cleanser, apply facial emollient – no steroids

Answer 12

Primary problem? seborrhea First medication product to suggest? Ketoconazole shampoo

Answer 13

Primary problem? seborrhea, “cradle cap” Treatment? baby oil with gentle massage

Answer 14

Measures of symptom and involvement: % Body surface area (BSA) involved Psoriasis Area and Severity Index (PASI) Physician’s Global Assessment (static PGA) Quality-of-life measures: Dermatology Life Quality Index (DLQI) Short Form (SF-36) Health Survey

Answer 15

``` Lesions (plaques): Erythmatous Red-violet in color At least 0.5 cm in diameter Well demarcated Typically covered by silver, flaking scales ```

Answer 16

Skin Involvement: Generalized over wide BSA Mild: less than or = to 5% BSA Moderate: PASI greater than or = to 8 (psoriasis area and severity index) Severe: PASI greater than or = to 10 OR DLQI is greater than or = to 10 or BSA is greater than or = to 10. (rule of 10s) (dermatology quality of life index)

Answer 17

Pruritis: More than 50% of patients have itching May be severe in some patients and require treatment to minimize excoriations from scratching

Answer 18

Other concerns: Lesions may be physically debilitating or socially isolating Potential comorbidities: PsA (psoriatic arthritis) depression, HTN,obesity, diabetes,Chrone's,anxiety, alcoholism

Answer 19

- -Minimizing or eliminating the signs of psoriasis such as plaques and scales - -Alleviating pruritus and minimizing excoriations - -Reducing the frequency of flare-ups - -Ensuring appropriate treatment of associated conditions such as PsA (psoriatic arthritis), hypertension, dyslipidemia, diabetes, clinical depression, or itching - -Avoiding or minimizing adverse effects from topical or systemic treatments used - -Providing cost-effective therapy - -Providing guidance or counseling as needed (e.g., stress-reduction techniques) - -Maintaining or improving the patient's quality of life

Answer 20

``` Reduce stress Regular exercise Weight management (aim for BMI 18.5-24.9) Moderation of alcohol consumption Cessation of smoking ```

Answer 21

For small areas or just a few patches Moisturizers / Emollients Oatmeal baths Sunscreen

Answer 22

Corticosteriods Vitamin D3 analogue-Calcipotriene Retinoids-Tazarotene Anthralin Coal Tar Salicylic Acid: Calcineurin Inhibitors- Pimecrimolimus:

Answer 23

Oral retinoid-Acitretin Oral Tcell & cytokine suppressor-Methotrexate and Cyclosporin Oral Tcell Inhibitor-Alefacept (Amevive) Oral Monoclonal Tcell Inhibitor-Efalizzumab (Raptiva) Interleukin Inhibitor-Ustekinumab (Stelera) Biologic Agents-TNFa inhibitors

Answer 24

Corticosteriods: (topical) cream or lotion (day) ointment (night) 2-4 times daily

Answer 25

Vitamin D3 analogue-Calcipotriene: (topical) ointment- 1 or 2 times daily or cream or foam- twice daily

Answer 26

Retinoids- Tazarotene: (topical) Once daily at bedtime

Answer 27

Anthralin: (topical) Apply only to thick plaque lesions for 2 hrs or less (use zinc oxide around) Then wipe off

Answer 28

Coal Tar: (topical) Apply in evening Wash off in morning

Answer 29

Salicylic Acid: | Shampoo-for scalp lesions

Answer 30

Calcineurin Inhibitors- Pimecrimolimus: (topical) Apply to intertriginous areas (folds)

Answer 31

``` Oral retinoid Acitretin: Not immunosuppressive Max response 3-6 months Do not drink alcohol ``` Reproductive age women: should not be or plan to get pregnant within 3 years of discontinuing drug

Answer 32

Methotrexate (oral) For psoriasis and psoriatic arthritis Onset 3-6 weeks Admin w/ folic acid 1-5mg/day to decrease nausea, bone marrow suppression, hepatic toxicity Contraindicated:pregnancy, cirrhosis, blood dyscrasias (disorders) Increases risk of hepatotoxicity (DM, obese, alcoholism, >4g total cumulative dose)

Answer 33

Cyclosporin (DMARD) oral Not recommended for use over 4 months-nephrotoxic Dose on ACTUAL body weight Many drug interactions:major 3A4 substrate, 3A4 & 2C9 inhibitor Contraindicated:systemic malignancy, untreated HTN, infections Increases elderly risk of HTN

Answer 34

Alefacept (Amevive) Dose: 15mg IM every week for 12 weeks (follow w/ 12 weeks non-treatment) Contraindicated:HIV Monitor: CD4 base count, get CD4 counts q 2 wks during therapy (hold for count

Answer 35

Efalizumab (Raptiva) Dose: single 0.7 mg/kg SC (conditioning dose) then 1 mg/kg SC weekly (max single dose not to exceed 200 mg) Monitior: Platelet count monthly, may extend to every 3 mo w/ prolonged course NO live or attenuated vaccines during therapy

Answer 36

Ustekinumab (Stelera) Dose 0-4 weeks: SC if under 100 kg; 90mh SC if over 100 kg then every 12 wks ``` Caution: -Avoid in active TB -Do not give concurrently with: ---live vaccines ---BCG ---pimecrolimus ---tacrolimus ---Echinacea (may decrease levels) ``` Monitor: PPD, CDC, signs of infection, antibody formation

Answer 37

``` Biologic Agents: Adalimumab (Humira) Etanercept (Enbrel) Infliximab (Remicade) Golimumab (Simponi) Certolizumab (Cimzia) ``` Dose: see insert ``` TB testing (PPD) on all patients (repeat yearly) HepB screen is recommended ``` Monitor CBC & LFT Do not Use: live vaccine CHF patients Patients w/ or family that has demylenating disease or MS

Answer 38

Topical agents + moisturizers as needed (If controlled step down to lowest effective dose or potency) Inadequate: Topical+phototherapy+ moisturizer as needed (If controlled step down to lowest effective dose or potency) Inadequate: Topical+systemic+ moisturizer as needed (If controlled step down to lowest effective dose or potency)

Answer 39

Systemic +/- topical or photo+ moisturizer as needed (If controlled step down to lowest effective dose or potency) Inadequate: More potent systemic+/- topical + moisturizer as needed (If controlled step down to lowest effective dose or potency) OR 2 systemics in rotation (rarely done) +/- topical+moisturizer as needed (If controlled step down to lowest effective dose or potency) Inadequate: Biologic +/- other agents + moisturizer as needed (If controlled step down to lowest effective dose or potency) NOTE: may consider biologics earlier or even as first line BUT expensive

Answer 40

Topical agent If UVB available: 1st line: UVB phototherapy (monotherapy) or UVB+Methotrexate ``` If No UVB: 1st line alpha order Adalimumab Cyclosporin Etanercept Infliximab Methotrexate PUVA ```

Answer 41

Nsaids or Local 1A steroids 1st DMARD 2nd DMARD 1st line TNFa inhibitor 2nd line TNFa inhibitor

Answer 42

Nsaid or local 1A steroid 1st line TNFa inhibitor 2nd line TNFa inhibitor

Answer 43

Last resort PUVA: Psoralen + UVA light MOA: Psoralen cross-links with DNA in presence of UVA light; effects immune response in skin and lymphocytes Reserved for patients with severe, refractory psoriasis Need skin biopsy of lesion to confirm diagnosis of psoriasis Efficacy: 90% with oral psoralens + UVA light Dosing 0.6-0.8mg/kg po every 2 hours before exposure to UVA light ``` Side effects: Serious burns Blistering Peeling Itching Nausea Potential increase in certain cancer rates ```

Answer 44

``` Costs of psoriasis therapy for moderate to severe disease: Cost of drug Cost of administration Cost of monitoring Cost of adverse effects Cost of failed treatment Cost of days off work Can be significant ($1000s), even with insurance ```

Answer 45

Fully inform patients / caregivers of benefits and risks of treatment options www. aad.org www. psoriasis.org

Answer 46

risk factors for psoriasis – winter treatment plan for this patient Moisturize appropriately, coal tar and steroid cream

Answer 47

Mild to moderate scaly dermatoses can often be effectively managed with topical non-prescription products Selection of products based on: Patient’s history Prior response to treatment Evaluation of risks vs. benefits of options Education of patients: Appropriate application of topical therapy Appropriate administration of oral therapy Follow-up should be a week after self-treatment begins

Rosacea and Scaly Dermatoses Flashcards

(71 cards)