Self Care: Infectious Dermatology

Verrucae (warts) are caused by _____

7-10% of the population has warts

Are they more frequent in children or adults?

Are most warts typically self resolving? How long does it take for them to shrink?

HPV

Warts are more frequent in children

yes most are self resolving —> takes 2 years to resolve

what are some risk fac?ors of warts (verrucae)

1. going barefoot

2. nail-biting

3. swimming pool and public shower use

4. immunocompromised status

5. chronic skin conditions

6. exisiting/prior warts

Pathophysiology of Warts:

• HPVs are double/single stranded _____ viruses

• How are warts transmitted?

• Infection through warts is limited to ________ ________

  • entry through ______ __________

• single stranded DNA

• trasnmitted through person to person + auto-inoculation (hands to face) + contaminated surface

• limited to EPIDERMAL tissues

• minor abrasions

The appearance, size, shape, and response of awrts to treatment vary by location on body and subtype of HPV

• Which types of HPV impact the hand?

HPV 2 + 4 + 27 + 57

The appearance, size, shape, and response of awrts to treatment vary by location on body and subtype of HPV

• which types of HPV impact the FOOT

HPV - 1 ONLY

What are some different clinical preentations you may see in HPV infection warts?

common

flat

plantar

mosaic

periungal

filoform

• location = hands

• population = children

• description =

  • skin-colored/ brown dome-shamped rough surface; typically painless

What type of warts are being described?

Is the following self- treatable?

• common warts = veruca VULGARIS

• YES treatable

• location = face

• population = children (rare in adults)

• description =

  • smooth, flat-topped, yellow- brown papules

What type of warts are being described?

Is the following self- treatable?

flat warts = veruca PLANA

• NO not self-treated bc/ more prone to irritation bc/ it is on the face

• location = feet

• population = adolescents + young adults

• description =

  • skin-colored flat calus like - can be painful

What type of warts are being described?

Is the following self- treatable?

plantar warts

YES it is treatable

• location = feet

• population = adolescents + young adults

• description =

  • multiple closley grouped plantar warts

What type of warts are being described?

Is the following self- treatable?

mosaic warts

• NO cannot be treated

• location = nails

• population = individuals who bite their nails

• description = thickened fissured cauliflower textured skin around the nail plate

What type of warts are being described?

Is the following self- treatable?

periungal warts

• NO cannot be treated

is there a cure for HPV infection?

are treatrments universal for all warts?

NO but you can provide sympotmatic releive

NO not all warts are treated the same

what is the wait and see approach used for treating HPV infection?

wait and see if the wart will regress on its own before trying treatment for symptomatic effects and to minimize the appearance

what are the goals of teating HPV infection?

• eliminate signs and symptoms

• avoid scarring

• prevent recurrence

• prevent HPV spread

What are some non-pharmcologic therapy options for patients with veracculae (warts) caused by HPV?

• Prevent HPV spread

  • Don’t cut, shave, or pick at warts

  • Keep wart covered

  • Don’t walk barefoot

  • Use a designated towel to dry off the wart

  • Don’t share accessories

• symptomatic relief

  • lamb’s wool or moleskin ON pressure points to relieve plantar wart discomfort

What are some pharmacologic therapy options for veruccae (warts) caused by HPV?

• salicyclic acid

• cryotheeapy

questionable:

• vitamin A

• zinc

• garlic

• duct tape

Salicylic acid: tx of HPV warts (verrucae)

• ________ agent: destroys cells —> induce immune response

• USED ONLY FOR ______ and ______ warts

• What are some PROs?

• What are some CONs?

keratinolytic

used for COMMON and PLANTAR

Pros = low cost, readily available, few adverse effects

cons = consistent + frequent application required, damages healthy skin, long duration of treatment, irritating to skin

Pharmacologic Therapy: Salicylic Acid

• ____% salicyclic acid liquid, gel

  • Are higher concentrations needed to treat common warts or plantar warts?

• _____%:

  • salicyclic acid ______, _______, and ______

  • this percentage is better for FEET due to THICKER skin

• 17%

  • Higher concentrations are needed to treat PLANTAR warts

• 40%

  • Salicylic acid plaster, pads, strips, and sticks

  • Better for feet compared to 17%

Salicyclic Acid:

• warts will begin to decrease in size within a couple of ______

• you SHOULD NOT treat longer than_____ ________

• reffereal is required if not resolved aftre full duraition

• how do you use it?

• Warts decrease in size within a couple of weeks

• Should NOT treat longer than 12 weeks on your own

• Wash hands before + after use —> soak the area in warm water for 5 minutes (SO ABSORPTION CAN INCREASE) —> wash and dry the affected area

Pharmacologic Therapy for HPV varaces (warts):

• ______ ______ used to destroy the lesion via FREEZING the tissue

• can patients admister themselves or does it have to be done at a doctor’s office?

• non-prescription products contain either _____ ______ or a mix of _______ ______ and _______

  • not as cold but still effective in wart destruction

• a _______ will form under the wart and cause it to fall of after ____ 10 days

• liquid nitrogen

• liquid form MUST be used in doctors office

• nitrous OXIDE or a MIX of DIMETHYL ETHER and PROPANE -> can be taken by patient nonpresctiption

• blister formation under the wart —> causes to fall after 10 days

Cryotherapy Counseling Points:

• the product is _________

• how often do you discard the application?

• risk of _____/__________ in patients with brown or black skin

• flammable

• discard after EACH use (one time use)

• hypo/hyper thyroidism in colored patients

HOW do you use cryotherapy?

1. Wash hands before and after

2. soak area in warm water for 5 minutes BEFORE use (easier for product to be absorbed)

3. wash and dry thoroughly

4. a pumice stone can be used to FILE the surface of the plantar wart

5. apply to the wart until a HALO appears around it

6. 20 seconds for common warts + 40 seconds for plantar

How long does it take for cryotherapy to work in patients with common vs plantar warts?

How can you tell if the medication is working?

common warts = 20 seconds

planar warts = 40 seconds

halo can signify is medication is working

is cryotherapy more effective than salycyclic acid?

NO

How can you determine whether to use saliyclic acid or cryotherapy for warts caused by HPV if they both have the same effectiveness?

You shouldn’t treat for longer than ____ weeks.

Can pregnant or lactating patients self-treat? Which option has teratogenic concerns?

• Cryotherapy may be better for warts on HANDS

• Treating every 2-4 weeks = best results

• Don’t treat for longer than 12 weeks

• NO: do not self-treat if pregnant or lactating

• Teratogenic concern w/ SALICYCLIC ACID

Children < ______ or those recovering from flu-like condiitons should NOT USE SALICYCLIC ACID

Children <____ SHOULD NOT use cryotherapy

Avoid BOTH in patients with ______ or poor ________. Why?

________ patients may need specialist refferal rather than OTC managment

children less than 3 OR recovering from flu —→ DONT USE salicyclic acid

children < 4 —> NO CRYOTHERAPY

avoid in patients with diabetes or poor circulation

SO 3 year old patient can do cryotherapy but nto salicyclic acid bc/ they have neuropathy on their feed—→ higher risk of ULCER formation

immunocompromised

What are some other methods beyond Salicyclic Acid and Cryotherapy which can be used to HPV Verrucae (warts)?

1. vitamin A

   • regulates _______ cells and ______

2. Zinc

   • Improves ______

   • may inhibit ____ _____________

3. Garlic

   • Inhibits cellular __________ of infected cells

4. Duct Tape

   1. Local irritation may stimulate ________ response

   2. Systematic reviews show NO superiority over placebo

1. vitamin A —> regulate epithelial cells + keratin

   1. may also disrupt HPV replication

2. zinc improves IMMUNITY

   1. may inhibit HPV replication

3. garlic = inhibits cellular proliferation

4. duct tape —> trigger immune

An 18-year-old female walks into your pharmacy complaining

of rough, skin colored bumps on the surface of her hands. She

says that the bumps don’t hurt, but they are annoying and

different from the calluses she usually gets. She has not tried

anything yet.

• What over-the-counter medication would you recommend?

• What could you give her non-pharmacologically?

• When would she need to see a doctor?

• OTC recommendation = salicyclic acid 17% (40% used for feet) or cryotherapy

• vitamin A, zinc, garlic, duct tape

• salysiclic acid 40%

• she would need to see doctor if no improvement after 12 weeks

How many bones are in the foot? How much of our total bones do they make up?

52 bones =

1/4 of all bones in body

75% of Americans will experience foot health problems once in their lives

What are the most common foot disorders?

• corns or calluses

• ingrown toenails or nail afflictions

• food infections

• foot structure injuries

are the following foot infections OR foot structure injuries?

• atheletes foot

• warts

foot infections

are the following foot infections OR foot structure injuries?

• bunions

• flat feed

• fallen arches

foot structures

Pathophysiology of Corns + Calluses:

Under normal conditions

basal skin mitotic rate = _____ _______ _________

What happens in corns + calluses?

increased _____ and _______leads to _________ basal cell mitotic rate = ______, ____ _____ of skin

Surface cellular desquamation

Increased friction and pressure lead to an increased basal cell mitotic rate = thicker, horny layer of skin

small, raised, sharply demarcatedm hyperkeratonic lesion with a central core

corns

Corns:

• color: ___ - colored, ____, or yellowish grey

• dry, hard corns:

  • bulb of great ____

  • dorsum of 4th or 5th ____

  • tips of ______ ___

• soft corns:

• ______ thickenings of skin

  • adjacent ____ (__ or ___th ___)

flesh colored, white, or yelowish grey

dry, hard corns:

• toe

• toe

• middle toe

soft:

• whitish

• toes (4th and 5th toes)

are soft or dry/hard stools more common?

dry/hard = more common

what is the most common cause of soft/dry/hard corns?

innapropriate tight-fitting shoes

yellow broad, raised, even thickening of skin on the

• heel

• ball of foot

• toes

• sides of foot

calluses

what are common causes of calluses?

• heel

• ball of foot

• toes

• sides of foot

what color are calluses and what are some common causes?

yellow

• friction

• walking barefoot

• structural biomechanical problems

what type of callus is being described?

• small

• translucent, localized center;

• painful w/ applied pressure

discrete- nucleated

What type of callus is being described?

• Large surface area

• No central core

• Looks like dry skin on the bottom of your feet

diffuse- shearing

What are some non-pharmacologic therapies for calluses and corns?

1. Gentle daily soaking in warm water for 5 minutes

• Softens dead skin; allows gentle removal with a callus file or pumice stone

2. Circular foam cushioning pads

   1. Relieve pressure from inflamed tissue

3. well-fitting, non-binding footwear

   1. distributes body weight evenly

4. orthopedic corrections (orthotics, surgical correction)

   1. anatomic toe deformities

What are some pharmacological options you can use to treat corns and calluses?

How does it work?

Salicyclic acid

• swells —> softens —> macerates —> desquamates affected epithelium

what % of salicyclic acid are in the following brands?

• pedinol hydrisalic gel

• dr. scholl’s corn / callys remover liquid

17%

what % of salicyclic acid are in the following brands?

• dr. scholl’s DURAGEL callus remover

• dr. scholl’s DURAGEL corn remover

• Curad MEDIPLAST corn, callus, and wart remover pad

40%

What are the different forms of salicyclic acid applications?

• Coloidon- like vehicle

• Plaster/ Disc / Pad

What are the advantages and disadvantages of COLLODION - like vehicle salicyclic acid?

advantages:

• adhere via flexible or rigid film

• prevent moisture evaporation

disadvantages:

• flammable + volatile (ppl can inhale and abuse)

• occlusion of water transport through the skin

What are the advantages of plaster/disc/pad salicyclic acid?

medication already on it so DIRECT and prolonged contact of dryg

quick resolution of symptoms

What are some general cautions to take when using salicyclic acid for corns and caluses?

inflamation or ulcer formation (higher risk in diabetes/neuropathy patients due to less nerve endings in feet)

Suboptimal technique

Hazardous in pregnancy + breastfeeding patients

can pregnant women use subsalicylate for corns/calluses/ warts?

NO

Corns + Caluses Counseling:

• How long is remission?

• What advice can you give patients about their shoes?

• shoudl they apply medication in the sourounding area of the corn/callus as well?

• when should you give them a refferel?

• days to months

• shoes that fit them and add cushions

• NO only apply ON the corn

• refferel IF more than 14 days of no imporovemnt

Exclusions for Self- Treatment of corns/ calluses:

1. diabetes melitus + peripheral circulatory disease condiitont hat contraindicates use of foot care products

2. anatomic defect or fault in body weight distribution

3. history of RHEUMATOID ARTHRITIS and complaint of painful metarsal heads or deviation of great toe

4. lesions hemorrhaging (bleeding) or oozing purulent material (NO OPEN WOUNDS)

5. EXTENSIVE or painful, debilitating corns/calluses on foot

Alopecia:

• are men or women more impacted?

• what race is most impacted?

• how much is spent a year to combat hair loss?

WHITE MEN most impacted

3.5 BILLLION spent each year on hair loss products

Pathophysiology of Alopecia:

• What are the 4 phases, and how long does each last?

1. Anagen (2-8 years)

2. Catagen (4-6 weeks)

3. Telogen (2-3 months)

4. Exogen

Which phase of hair growth is being described?

• active hair growth

anagen phase

Which phase of hair growth is being described?

• end of active hair growth

• Individual hair cut off from blood supply

Catagen (get Cut off from blood supply)

Which phase of hair growth is being described?

• resting period

• strabds renian in their follicles but not actively growing

Tekogen

Which phase of hair growth is being described?

• hair strands are released from follicles and fall out

Exogen phase

In general what are some things that can cause hair loss?

1. hormonal changes

2. medications

3. dietary changes

4. physiological stress

5. chronic illness

What are some hormonal changes that can lead to hair loss?

• POSTPARTUM

• hyPERANDROGEN conditions

• monopause

What are some examples of phsyiologicla stress that can lead to hair loss?

1. fever / infections

2. hemmorage

3. trauma

What are some examples of chronic illness that can lead to hair loss?

1. endocrine disorders (hypo/hyper thryoidism + diabetes)

2. automimmune diseases (rheumatoid arthritis + lupus)

3. eating disorders

What are some examples of medications that can lead to hair loss?

1. anticonvulsants (levicitiracim + lamotrigine + gabapentin)

2. chemotherapy

3. ACE inhibitors

4. allopurinol

5. androgenic action

6. anticoagulants

7. antidepressents

8. beta-blockers

9. cholesterol- lowering drugs

What are some examples of dietary changes that can lead to hair loss?

• rapid weight LOSS

• protein restriction / deficiency

• zinc or biotin or iron deficiency

Is the following describing nonscarring or scarring allopecia?

• androgenetic alopecia (AGA) - ONLY SELF TREATABLE OPTION

• alopecia areata

• anagen effluvium

• telogen effluvium

• cosmetic hair damage

• trictillomania

• tinea captits

nonscarring alopeica

what are the two types of alopecia?

nonscarring + scarring

Is the following describing nonscarring or scarring allopecia?

• due to LUPUS

• severe forms of tinea capitis

• damaging hair practices (braiding or permanent waving)

scarring

What type of alopecia is being described?

• Hereditary hair loss

• Gradual onset starting from the CROWN

androgenetic alopecia (AGA) - TREATABLE

What type of alopecia is being described?

• AUTOIMMUNE

• abrupt onset with visible PATCHY AREAS

allopecia aeretea

What type of alopecia is being described?

• chemotherapy

• diffuse, abrupt onset within days of exposure

anagen effuvium

What type of alopecia is being described?

• metabolic/ hormonal disturbances

• diffuse, abbrupt onset with rapid hair thinning

telogenn efflvium

What type of alopecia is being described?

• metabolic / hormonal disturbances

• diffuse, abrupt onset with rapid hair thinning

telogen effluvium

What type of alopecia is being described?

• harsh hair practice

• broken hairs

cosmetic hair damage

What type of alopecia is being described?

• psychiatric illness

• twisted and broken off hairs visible in patchy areas

trichotillomania

What type of alopecia is being described?

• fungal infection

• abrupt onset with visible round red pathy areas

tinea captilis

who should NOT get treatment for alopecia?

• less than 18 years old

• prostpartum + pregnant + recent discontinuation of oral contraceptives + sudden or severe hair loss

• endocrine dysfunction + ongoing medical treatments + fungal infection or trichtolomnia + fever or inflammation 3-6 months prior + skin lesion (autoimmune disease or infection)

• positive hair-pull test + sudden or pathy hair loss + no family history of hair loss + unkown reason for hair loss + loss of eyebrowns + eyelash + nail pitting/ nail abnormalitities + red painful scalp

How much is a normal amount of hair to lose daily?

50-100 strands

What is the ONLY FDA-approved agent for the self-treatment of AGA?

Which forms are approved for men vs. women?

Minoxidil (Rogaine)

Men= 2% + 5% solution ( 1mlL 2x daily) and 5% foam solution (1/2 capful 2x daily)

Women = 2% solution (1mL 2x daily) + 5% foam solution (1/2 capful 2x daily) 5% SOLUTION NOT RECOMMENDED

what is the MOA of minodixil?

how can it be used in men vs women?

increases hair follicle BLOOD FLOW + prolongs ANAGEN phase

men = used for head crown baldness

women = fronotoparietal area thinning

What are the different dosage forms of minoxidil (rogaine) ?

How is it meant to be taken? How long do you keep it on your scalp?

spray + dropper

apply to clean + dry scalp

LEAVE ON FOR 2-4 hours for drug to penetrate scalp

What are the adverse effects of minoxidil?

• itching

• irritation

• dryness

• hypertrichosis

What are some counseling points for patients considering minoxidil?

• DO NOT TAKE WHILE PREGNANT (category C)

• discontinue if no improvement in 4-6 months

• increase in hair LOSS MAY occur within first few weeks of use (old hair falls to allow new hairs to grow)

• must continue to use product INDEFINETLY to maintian new growth

• avoid use the day OF and for 24 hours after using permanent HAIR COLOR products

• patients who require prescription FINASTERIDE may STILL use topical minoxidil

• does NOT cause permanant hair loss

• highly TOXIC to pets, even small amounts can cause

how long should you take minoxidil before discontinuing it?

4-6 months

which medication is highly toxic to pets, even small amounts can cause cardiac problems

minoxidil (rogaine)