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flat lesions of any shape or size that differ from surrounding skin because of their color (e.g. birthmark or freckle)
small, solid, elevated lesions that are less than 1 cm in diameter (not fluid-filled)
a mesa-like elevation that occupies a relatively large surface area in comparison with its height above the skin
- palpable, solid, round or ellipsoidal lesions with varying depth of involvement into the skin
- (papules that extend under the skin)
rounded or flat-topped papules or plaques that are characteristically evanescent, disappearing within hours and usually itch (usually from allergic rxn)
Define vesicle and bullae
blisters; vesicles are < 0.5 cm in diameter and bullae are > 0.5 cm in diameter
Characteristics of xerosis
- AKA: dry skin, winter itch
- decreased water content in stratum corneum
- s/s: roughness, scaling, loss of flexibility, fissures, cracks, inflammation and/or pruritis
What is the most common dermatologic problem in children?
S/S and other names for atopic dermatitis
- aka: eczema, "the itch that rashes"
- Chronic, relapsing (relapsing and remitting)
- intensely pruritic
- oozing vesicles with or without excoriations
what is the atopic triad?
- allergic rhinitis
- atopic dermatitis
What areas are most common for atopic dermatitis at which ages?
- 0-2 years: face and scalp
- 2 years - puberty: wrists, ankles, neck
- Adult: upper arms, back, wrists
How is atopic dermatitis diagnosed?
- If pt has itchy skin + 3 of the following:
- onset < 2 years
- hx of skin crease involvement
- hx of generally dry skin
- personal or 1st degree relative hx of other atopic disease
- visible flexural dermatitis
Non pharmacologic treatment of atopic dermatitis
- decrease exposure to triggers
- drink water
- diet (questionable)
- bathing (soak & seal - apply moisturizer within 3 min)
- keep nails short
- wear loose fitting cotton clothing
- avoid all triggers
What is the teaspoon rule?
- tells the amount of moisturizer to use
- one teaspoon per arm, chest, abdomen, upper back, lower back, each thigh, each shin
Compare emollients vs. moisturizers
- Emollients smooth the skin
- Moisturizers hydrate the skin
What do humectants and keratolytics do?
- humectants attract water
- keratolytics soften scales
Exclusion for self treatment of atopic dermatitis
- 1. severe condition with intense pruritis and crusting (severe flare)
- 2. involvement of large area of the body
- 3. less than 2 years of age
- 4. infected lesions
- 5. treatment for 7 days with no resolution
Treatment algorithm for atopic dermatitis
- Weeping lesion:
- cool tap water compress, astringents
- topical antibiotics if infx present (honey-colored crusting)
- Dry lesion:
- moisturizers and emollients throughout the day plus:
- colloidal oatmeal
- topical glucocorticoids (up to 7 days)
- oral antihistamines
- topical calcineurin inhibitors
- cyclosporine A, azathioprine, interferon gamma, mycophenolate mofetil, phototherapy
Should topical antihistamines and anesthetics be used in atopic dermatitis and contact dermatitis? Why or why not?
No because they are skin sensitizers
What are the 2 types of contact dermatitis and common causes?
- Irritant contact dermatitis - caused by exposure to irritant (e.g. strong acids/bases, detergents, fiberglass, leather, solvents, etc.)
- Allergic contact dermatitis - caused by exposure to allergen (poison ivy/oak/sumac, metal)
What is the chemical that causes the allergic reaction to poison ivy?
s/s of contact dermatitis
- inflamed, swollen, red skin
- vesicles and bullae
- intense itching - may lead to skin breakdown and open lesions
Nonpharmacologic treatment of contact dermatitis
- remove irritant/allergen
- wash self and objects with soap and water
- men should shave
- trim nails
Treatment algorithm for contact dermatitis
- Weeping lesions:
- tap water compress
- Dry lesions:
- colloidal oatmeal
- shake lotion, sodium bicarb compress/paste
- topical corticosteroid
- counterirritants, oral antihistamines
- oral steroids (1mg/kg/day tapered over 2-3 weeks)
can topical corticosteroids/glucocorticoids be applied to broken skin? can counterirritants?
- steroids can
- counterirritants cannot
Exclusions for self-treatment of contact dermatitis
- Less than 2 years old
- greater than 2 weeks duration
- greater than 25% of body surface area
- extreme itching, irritation, or severe vesicle and bullae formation
- swelling of the body and/or extremities
- swollen eyes
- involvement of mucous membranes
- impairment of daily activities (e.g. it's on the bottoms of feet, hands, etc.)
Signs/symptoms of first degree and second degree sunburns
- First Degree: superficial burn, mild erythema, tenderness, pain, edema, pruritis, macular
- Second Degree: visicles, bullae, fever, shills, weakness, shock
What is the max SPF there is?
How is the UVA protection with sunscreen rated?
4 star rating (low, medium, high, highest)
How much sunscreen is needed per body part for proper protection?
Define "water resistant" and "very water resistant" in terms of sunscreens
- water resistant retains SPF for at least 40 minutes when sweating or swimming
- very water resistant retains SPF for at least 80 minutes when sweating or swimming
What is the difference between organic and inorganic sunscreens?
- Organic - the active ingredient absorbs at least 85% of UV rays
- Inorganic - the active ingredient reflects or scatters all light (physical barrier)
What are the major categories of sunscreen ingredients?
- PABA and derivatives
- Dibenzoylmethane Derivatives
What agents fall under which categories of sunscreens?
- PABA and derivatives - Aminobenzoic Acid (PABA), Padimate O
- Anthranilates - Menthyl anthranilate
- Benzophenones - Dioxybenzone, Oxybenzone, Sulisobenzone
- Cinnamates - Cinoxate, Octyl methoxycinnamate, Octocrylene
- Dibenzoylmethane Derivatives - Avobenzone
- Salicylates - Octyl salicylate, homosalate, Trolamin salicylate
- Misc. - Terephthalyidene dicamphor sulphonic acid, Phenyl benzimidazole, Titanium dioxide, Zinc dioxide
Which sunscreens are sensitizers?
- PABA (aminobenzoic acid)
- Benzophenones (dioxybenzone, oxybenzone, sulisobenzone)
Which sunscreens are weak and do not adhere well?
the salicylates (octyl salicylate, homosalate, trolamin salicylate)
Which sunscreen provides protection for the entire UVA range, and what is its problem?
Avobenzone - it is not photostable
Nonpharmacologic treatment of sunburn
- cool with tap water for 10-30 min
- do not pull loose skin
- stay hydrated!
Treatment algorithm for sunburn
- Dry Burn:
- skin protectant, emollient/moisturizer
- Weeping Burn (2nd degree):
- cool tap water compress/soak
- topical antibiotics if infx present
- Painful Burn:
- local anesthetics (3-4x/day)
- oral NSAIDs
- topical hydrocortisone
Should astringents or counterirritants be used to treat sunburns?
Exclusions for self-treatment of sunburn
- more than 2% of body surface area (for regular burns, not sunburn)
- treatment for 7 days with no resolution
- generalized edema
Which type of insects bite pattern is a linear formation?
Characteristics of Lyme disease
- Spirochete found in deer ticks
- Initial rash is papule that enlarges to a bulls-eye rash that disappears in 3-4 weeks
- Infection spreads and pt experiences flulike sx and muscle aches
- Years later - neurologic and cardiac sx
- Finally, arthritis and red discoloration on hands, wrists, feet, or ankles
Are insect repellants effective for stinging or biting insects?
biting, not stinging
How does DEET work, and how should it be used?
- It discourages insect approach
- Apply max of q6hours (nmt qd in kids)
- spray clothing
- it decreases the efficacy of SPF
Alternative insect repellants
- lemon eucalyptus
- soybean oil
- tea tree oil
Nonpharmacologic treatment for insect bites/stings
- Remove stinger
- ice packs
- trim fingernails
- RICE therapy (rest, ice, compression, elevation)
- Bedbugs: Vacuum daily, petroleum jelly on bed legs
Treatment algorithm for insect bites/stings
- topical antihistamines, topical hydrocortisone
- counterirritants, shake lotion
- local anesthetics, oral NSAIDS
Exclusions for self treatment of insect bite/stings
- Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing
- Hx of significant allergic response to any sting
- Allergic response away from sting
- Less than 2 y.o.
- tick bite
- spider bite requiring medical attention (brown recluse, black widow)
- s/s of infx
Treatment for scabies
- Permethrin Rx
- Cover entire body, wash in 8-12 h, retreat if necessary
- Lots of counseling necessary
Nonpharmacologic treatment of pediculosis
- Nit comb over a 10 day period (as monotx, or following pediculocides)
- Petrolatum for eyebrows or eyelashes
- Vacuuming furniture/rugs
- Wash bedding and clothes in washer and dry in dryer
- Seal unwashable items in plastic bag for 2 weeks
Pharmacologic treatment for pediculosis
- Pediculicides - neurotoxins that cause paralysis - pyrethrin, permethrin (ovicidal)
- Benzyl alcohol lotion - suffocates the lice (not ovicidal)
Counseling re: pediculicides
- May cause scalp irritation
- ONLY for actual infestation (don't use as prevention)
- Must use nit comb
- Only repeat if necessary
- Do not use on eyebrows or eyelashes
Exclusions for self-treatment of pediculosis
- Hypersensitivity to chrysanthemums or ragweed
- Evidence of secondary infx
- Less than 2 y.o.
- Infestation of eyebrows or eyelashes (sign of sexual abuse)
- Pregnancy or lactation
Important points regarding product selection for dermatologic conditions
- If it's wet, dry it
- If it's dry, wet it
- Water in oil is more effective (e.g. ointment)
- Oil in water is more esthetic (e.g. lotion) and may evaporate, causing a drying effect
- Do not use ointments, shake lotions, or counterirritants on weeping lesions
- Topical antihistamines and anesthetics are known sensitizers
- Aerosol products may be drying or irritating and are not protective
- Avoid camphor in children
- Ointments > Creams > Lotions
Atopic dermatitis is a _______ disease state that requires both _________ and ____________ treatment to maintain the integrity of the stratum corneum. How do we prevent flares?
- Preventive and active
- use emollients and moisturizers to prevent flares
When treating urushiol induced contact dermatitis what is the #1 thing to do?
- Eliminate the urushiol
- Must use nonpharmacologic measures to prevent recontamination
What type of product is best for preventing sunburn?
A product with good UVA and UVB protection. Be sure to apply it correctly.
What is the difference in treatment of insect bites vs. insect stings?
What is extremely important to consider with the use of pediculocides?
- Only treat with them when necessary
- Do not use for prevention
- Patients must take non-pharm measures to control the infestation
Why should topical corticosteroids not be applied to eye area or eyelids?
They can thin the skin (epidermal atrophy)
When should sunscreen be applied and how often?
15-30 minutes prior to sun exposure and reapplied q 2-3 hours