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seborrheic dermatitis
-chronic inflammatory dermatitis of the scalp, face, and/or trunk
-occurs in areas of greatest sebaceous activity
-red, scaly, itchy rash, yellow, greasy scales with erythema
-hyperproliferation with 3x normal turnover rate d/t Malassezia
Infant SD Presentation
-infantile cradle cap
-usually self limiting
-massage scalp with baby oil
-nonmedicated shampoos
-emollients/moisturizers for face
Adult SD Presentation
-dull, yellowish, oily scales on red skin
-well demarcated on pruritus is common
-common on scalp and middle face
-may have exudation and crusting
SD Self Care Treatment
-medicated shampoo (pyrithione zinc 1-2%, selenium sulfide 1%, ketoconazole 1%, coal tar 0.5-5%, salicylic acid or sulfur as alternative)
-emollients/moisturizers
-hydrocortisone (applied to affected area NTE 7 days)
Medicated Shampoos
-more aggressive
-apply daily to 1-2 weeks, then at least 2-3 times/week x 4 weeks, then weekly once controlled
-exception: ketoconazole 2x/week for up to 8 week with >3 days between uses, then weekly
-use regardless of symptom location as shampoo and on affected areas
Alternatives
-salicylic acid or sulfur products
-keratolytic: normalizes proliferation
-slower acting than other products
-nonmedicated shampoo/dish soap: soften crusts and scales
-topical antifungal creams
Psoriasis
-chronic inflammatory disease
-plaque psoriasis most common
-unpredictable relapsing and remitting course
-hyperproliferation with 6-8 x normal turnover rate
-unknown cause but environmental, infections, Rx drugs, stress, alcohol, and tobacco play a role
Psoriasis Presentation
-thick scales on well defined, raised plaques
-pinpoint bleeding when scale is removed
-common on extensor surfaces, lumbar back, scalp, ears, and genitals
Psoriasis self care treatment
-only for mild (few isolated lesions < size of a quarter)
-regular use of moisturizers
-hydrocortisone: ointment usually preferred ( more occlusive), wait 30 min then apply emollient
-medicated shampoo: coal tar, salicylic acid
-contact PCP if no improvement in 1-2 weeks
Nonpharm treatment for Psoriasis
-bathe 2-3 times per week with lubr bath products in tepid water
-emollient 4x daily
-remove scales with soft cloth
-reduce stress
-avoid injury
-weight loss
-smoking cessation
-avoid EtOH
Exclusions to Self Care for Psoriasis
-children < 2 years
-involvement of >5% of BSA
-more than a few lesions or any one lesion larger than a quarter
-associated with joint pain
Irritant Contact Dermatitis
-direct tissue damage
-itching, erythema, stinging/burning, edema
-occurs in min-hours possibly after 1st exposure
Allergic Contact Dermatitis
-immune response to antigen
-itching, erythema, vesicles, papules, edema
-occurs in days, most often in sensitized pts
-type IV hypersensitivity
Causative Agents ICD
-detergents
-hand sanitizer
-soap
-alkalis or acids
-urine/feces
ICD Presentation (Irritant Contact Dermatitis)
-dry, cracked skin, or inflamed, erythematous skin
-often with pruritus', burning, or stinging
ICD Treatment (Skin)
-avoid exposure
-wash with hypoallergenic soap
-colloidal oatmeal baths
-emollients/moisturizers
-urea or glycerin is benifical
-petrolatum is gold standard for preventing epidermal water loss
-do not use hydrocortisone
-protective clothing
-contact PCP if no improvement after 1 week
Causative Agents ACD
-poison ivy/oak/sumac
-nickel
-latex
-fragrances
-cosmetics
Urushiol
-oleoresin in Toxicodendron plants
-black tarry lacquer released with plant damage
-enters skin within 10 min
-80% pop is sensitive
ACD presentation (Allergic Contact Dermatitis)
pruritus, erythema, papules, vesicles/bullae (vesicle fluid does not contain antigen)
Mild ACD (Allergic Contact Dermatitis)
linear streaks in distinct patches
Moderate ACD (Allergic Contact Dermatitis)
vesicles and erythematous swelling
Severe ACD (Allergic Contact Dermatitis)
extensive involvement with edema of face and/or extremities
ACD Treatment
-remove antigen from skin and clothing ASAP
-symptomatic treatment: hydrocortisone cream, antihistamines, astringent compresses, colloidal oatmeal baths, calamine lotion
-zanfel to remove resin
-protective clothing
ACD (Allergic Contact Dermatitis) Exclusions to Self-Care
-age < 2
-mucous membrane or genital involvement
-extensive involvement >20% BSA
-numerous large bullae
-signs of infection
-symptoms developing after sun exposure
-failure of self treatment after 1-2 weeks
Cleansing
-most effective within 10 min of exposure
-Tecnu Outdoor Skin Cleanser: can use up to 8hrs after exposure, cleanse for > 2 min, can be used without water
-Ivarest Cleansing Foam
-Dial Ultra dishwashing soap
Hydrocortisone
-effective for mild-moderate ACD
-helps with inflammation, pruritus and erythema
-avoid on eyes/eyelids
-cream preferred over ointment if weeping
-apply 2-4 times daily for up to 7 days
Astringents
-useful if weeping
-Burow's solution (aluminum acetate 5%): mic tablet/packet with 1 pt of water, soak 15-30min 3-4 times daily
-witch hazel
-wet dressings or cool compresses
-20-30min, 4-6 times daily
Calamine
-astringent, protectant, and soothing agent
-apply 3-4 times daily (shake prior to sue, avoid on large areas/mucous membranes)
Zanfel (R)
-only product known to remove urushiol (oil from poison ivy) from skin
-may relieve itching and pain within 30 seconds
-can use any time after exposure
-later 1.5" to paste in hands rub on area up to 3 min, rinse
-may to 2nd treatment if needed
Barrier Products
-Ivy Block Lotion (bentoquatam 5%): effective when applies >15 min before, apply generously and reapply q4h or prn, not currently available in US
-IvyX Pre Contact Solution: claims to tighten skin pores, not sticky, greasy, or clay like, not well studied but may be effective in combo with post exposure cleansing
Salivary Glands
-responsible for secreting saliva
-normal function promotes good oral health
Tongue
-muscular organ
-vital for chewing and swallowing food
Root
below gum line
Crown
above gums, surface for affective chewing
Enamel
hard Ca P salts, protection
Dentin
softer, largest part of structure
Pulp
vasculature neural tissue, continuous with surroundings
Cementum
hard tissue, helps ligament attach
Gum (gingiva)
Firm but soft tissue surrounding the alveolar process, when attached =pink
Dental Caries
Cavities
Dental Caries Risks
poor oral hygiene , xerostomia, tobacco, alcohol, diabetes, medication (anticholinergic), orthodontic devices, high cariogenic foods, head and neck radiation
Dental Caries Pathophysiology
plaque bacteria generate acid from dietary carbohydrates which demineralizes tooth enamel and dentin, leading to the formation of soft carious lesions, plaque
Dental Caries Prevention Nonpharm
-food choices: low cariogenic food (< 15% sugar), eating fresh fruit, high protein, and fibrous food
-plaque removal devices
Dental Caries Prevention Pharmacologic
fluoride (incorporated into growing teeth makes more resistant to break down, interferes with bacterial growth), dentifrices, mouth rinse
Whitening Products
-available: toothpastes (surface abrasives), strips (low hydrogen peroxide then professional), activated charcoal and other home based methods (abrasive, thought to absorb stains, don't recommend
-concerns: tooth sensitivity, irritated gums, painful for those with cracks, not appropriate for those with cavities or dental work being done
Gingivitis
inflammation of the gums
gingivitis pathophysiology
- accumulation of bacterial plaque
-drugs: Ca2+ channel blockers, anticholinergic, antidepressants
-smoking
-hormones: pregnant
Gingivitis Clinical Presentation
-erythema (redness), enlarged gingiva, inflammation
-common, reversible, mild but can escalate into periodontitis (ligament/bone attachment compromised/lost, tooth unprotected)
Gingivitis Prevention
-calculus prevention
-plaque control
Halitosis
bad breath
Halitosis Pathophysiology
-oral and systemic conditions
-impacted food
-cavities, infection
-tobacco products
-certain food: high sulfur (volatile sulfur compounds)
Halitosis Prevention
-physical: hydration, brushing teeth (fluoride), get back of tongue, mouth wash, flossing, tongue scrapper
-chemical: zinc salts, chloride dioxides
Denture Related Problems Pathophysiology
-similar to natural teeth
-fungal and bacterial growth
-chronic atrophic candidiasis (yeast infection of mouth)
-angular cheilitis (cracking of corner of mouth): terbinafine cream
Denture Related Problems Prevention
-regular cleaning
-brushing
-soaking in alkaline peroxide or sodium hypochlorite
-brush again to remove products
Exclusions for Self Treatment of Hygiene Related Oral Disorders
-symptoms of toothache
-development of a mottled appearance to the teeth
-bleeding, swelling, or reddened gums
-persistent mouth odor despite regular hygiene
tooth hypersensitivity pathophysiology
-dentin exposure
-dentin tubules open
Tooth Hypersensitivity clinical presentation
pain when exposes to certain stimuli (heat, cold, acid, sweet, sour)
Tooth Hypersensitivity Nonpharm
-avoid predisposing factors
Sensodyne fresh impact
-Crest Pro-Health
Tooth Hypersensitivity Pharmacologic Treatment
-Potassium Salts: depolarize the excited nerves in pulp
-Arginine: minimize the flow of fluid
-treat as long as needed but if not relieved in 4-6 weeks refer to dentist
Tooth Hypersensitivity Exclusions for Self Treatment
-toothache
-mouth soreness associated with poor fitting dentures
-presence of fever or swelling
-loose gums
-bleeding gums in the absence of trauma
-broken/knocked out teeth
-severe tooth pain triggered or worsened by hot, cold, or chewing
-trauma to mouth
Teething
-very young, when new teeth come in
-irritable, pain, redness, drooling
Teething Nonpharm.
-gum massage
-teeth ring
Teething Pharmacologic
-topical oral anesthetics (not FDA recommended): oral benzocaine, oral lidocaine, can cause toxicity
-homeopathic remedies (don't recommend): teething tablets, toxicity
-Analgesics: Acetaminophen 10-15mg/kg every 4-6 hrs and Ibuprofen 5-10 mg/kg every 6-8 hrs
Aphthous Stomatitis
canker sore
Aphthous Stomatitis Pathophysiology
-cause unknown
-precipitating factors: genetic, trauma, diet, HIV/AIDS, neutrophil dysfunction, vitamin deficiency
Aphthous Stomatitis Clinical Presentation
-epithelial ulceration in mucosal surface of movable mouth parts
-round/oval
-flat/crateriform
-gray to grayish yellow
Aphthous Stomatitis Nonpharm
-fix nutrition deficiency
-avoid certain foods
-ice (NO HEAT)
Aphthous Stomatitis Pharmacologic
-carbamide peroxide (10-15%) or hydrogen peroxide (1.5%) applied to affected area and allowed to remain for 1 min before expectorating, use up to 7 days: cleanse and soothe
-topical oral protectants: canker covers, reduces friction
Exclusion for Self Care of Aphthous Stomatitis
-lesions associated with underlying pathology
-lesions present for > 14 days
-frequently recurring lesions'-symptoms of systemic illness
-failure of prior appropriate self treatment
Herpes Simplex Labialis Pathophysiology
-infection is contagious
-transmitted by direct contain
-fluid in pustules contains virus
-reactivation criteria: stress, fatigue, infection, mensuration, fever
Herpes Simplex Labialis Clinical Presentation
-affects the lip or areas bordering the lips
-onset often preceded by prodromal symptoms
-small red papules of fluid containing vesicles
-lesions can coalesce
-crust
Exclusion of Self Treatment of Herpes Simplex Labialis
-lesions present for > 14 days
-increased frequency of outbreaks
-compromised immunity
-symptoms of infection (fever, swollen glands, rash)
-no previous diagnosis of cold sores
-recurrence
Herpes Simplex Labialis Nonpharm
-gentle cleansing and hand hygiene
-avoiding precipitating factors
-SPF
Herpes Simplex Labialis Pharmacologic
-topical skin protectants: after meals, avoiding eating/drinking for 30 min after
-external anesthetics and analgesics: benzocaine, relieve itching/burning
-Docosanol 10% (Abreva): apply at first sign of an outbreak, 5 times a day, until healed for max of 10 days, decrease healing time by 1 day, spendy
-campho-phenique: cheaper, pain relief, antiseptic
-antivirals: Acyclovir, Valacyclovir, and Famciclovir (prescription)
Xerostomia
dry mouth, decreased salivation
Xerostomia Pathophysiology
-Sjogren syndrome: autoimmune condition, salivary gland dysfunction
-diabetes mellitus
-radiation therapy
Xerostomia Clinical Presentation
-difficulty talking and swallowing
-stomatitis, burning tongue, and halitosis
-unmoistened food can't be tasted
-sensitive teeth
-caries around the root surfaces of teeth and tooth decay
Xerostomia Nonpharm.
-avoid drying substances like tobacco, caffeine, hot spicy food, and alcohol
-modify medication schedules of drying meds (antidepressants)
-limit sugar, starch, and acid intake
-Xylitol: stimulate salivary flow but GI side effects
-stay hydrated
Xerostomia Pharmacologics
artificial saliva
Xerostomia Exclusions for Self Care
-tooth erosion, decalcification and decay
-candidiasis, gingivitis, and periodontitis
-moth soreness associated with poor fitting dentures
-presence of fever or swelling
-bleeding gums in the absence of trauma
-loose teeth
-severe tooth pain triggered or worsened by hot, cold, or chewing
-Sjogren syndrome
-salivary gland stones
Levocetirizine (Xyzal)
second generation antihistamine
Oxymetazoline (Afrin)
nasal decongestant
Budesonide (Rhinocort)
intranasal corticosteroid
Chlorpheniramine (Clor Trimenton)
first generation antihistamine
Azelastine (Astepro)
intranasal antihistamine
Anticholinergic effects
can't see, can't pee, can't spit, can't shit
A patient, HS comes into your pharmacy with a bottle of Robitussin DM with a curious/confused look on her face. She asks "What can I do to help me with this cough?". After motioning toward you with the bottle, she states, "I'll try anything, I can't sleep because of all this gunk in my chest that I keep coughing up." What counseling points can you provide:
- Robitussin Dm contains a pro and anti tussive and this is not a product I would recommend
- SCHOLAR MAC to gain a better insight into patients clinical picture
-Drink plenty of water as this will allow for the cough to become more productive
Water is just as effective as guaifenesin making a cough productive.
True
Patient BG presents to your pharmacy stating "this cough won't let me sleep". He shares further complaints of a sore throat that is improving with some congestion and headache after his return from vacation yesterday.
recommend pseudoephedrine (sudafed)
BG is wondering if his wife can take the same medication since she is having a similar experience after returning. After going through SCHOLAR MAC you learn that BG's wife is taking losartan and amlodipine. Would you give the same recommendation to BG's wife that you gave to him?
-no I would not
-hypertension medication indicates hypertension
-contraindicated with decongestant, contracts blood vessels
BG returns to your pharmacy a few weeks later. He says "Now if only I could get my eyes and nose to stop watering." He goes on to say this happens every year and gets worse when he goes outside in the spring or fall. What is a non pharm recommendation you can give?
-check AQI before going outside, avoidance
-HEPA filter
What is first line pharm treatment would you give?
intranasal corticosteroids
Dermatitis
inflammatory reaction pattern involving epidermis and dermis
Dermatitis Treatment Goals
-control symptoms
-decrease number and severity of flares
-increase disease free periods
-minimize exacerbating factors
-minimize adverse effects from therapy
-educate on trigger avoidance and hydration of the skin
Atopic Dermatitis
-chronic, pruritic inflammatory skin disease (follows relapsing course, usually with early age of onset and xerosis)
-dysfunctional skin barrier and dysregulation of immune system (often w/ increase in CD4 T helper cells & cytokines, filaggrin gene mutation, increased TEWL, deficient skin barrier)
atopic triad
AD, asthma, allergic rhinitis
AD Presentation Infants
face, neck, trunk, and extensor extremities
AD Presentation Young Children
neck, flexor extremities, wrists, hands, ankles, feet, inside elbows, behind knees
AD Presentation Older Children and Adults
neck, flexor extremities, and hands
thickened hyperkeratotic plaques with lichenification
Exacerbating Factors AD
-temperature extremes
-low humidity
-irritants and allergens
-infections
-food
-emotional stress
-excessive bathing