315 Exam 3 Dermatology, Stings, Pediculosis, Acne

Dry Skin

Xerosis. Characterized by roughness, scaling, cracking, fissuring, and redness of the skin. Can be itchy and caused by environmental factors. Usually temporary.

Causes of dry skin

Barrier dysfunction leading to water-holding capacity. Decreased lipid components such as ceramides, free fatty acids, and cholesterol. Leads to epidermal water loss. Advanced age can lead to thinner epithelium and decreased lipids. Also associated with dehydration, hypothyroidism, and renal failure.

Treatment of dry skin

Modification of environment and bathing habits. Limit time and water temperature. Moisturize immediately after bathing within 3 minutes, 3-4x a day. Modify room humidification and hydration.

How to increase skin hydration

Bath oils: mineral or vegetable plus a surfactant. Create a slippery surface. Diluted too minimally effective. Colloidal oatmeal can help with itching.

Moisturizers

Usually 60-80% water which will evaporate and leave behind emollients (keep in moisture). Can include emulsifiers which keep water and lipids together, humectants which help the skin retain water, and ceramides to replace lipids. Can include different oils, plant oils, vitamins, fragrances, colors. Apply liberally 3-4x a day and to hands after washing.

Examples of emollients

Silicone, dimethicone oils, petrolatum

Examples of emulsifiers

Potassium cetyl sulfate and polysorbates

Examples of humectants

Glycerin, AHAs, urea, propylene glycol

Sarna

Is a counterirritant. Contains camphor and menthol.

Lotions and Creams

Oil in water emulsions. Less greasy and easily applied. Good for warm weather.

Ointments

Water in oil emulsions. Very occlusive. Difficult to spread. Do not use on oozing legions, infected areas, lacerations in intertriginous areas, mucous membranes, or acne prone skin. Not good for warm weather.

Gels

Feel good on skin but have drying effects.

Butters

Stiffer formulations

Eczema

Group of conditions that cause the skin to become itchy and inflamed. Can be red in lighter skin tones and brown/purple/grey in darker skin tones. Inflammation. Genetics and environmental triggers play a role.

Atopic dermatitis

Most common. Begins in childhood and lasts chronically. More likely to get it if there is a family history. Characterized by episodic flares and period of remission. Caused by alterations in epidermal barrier and immune system. Asthma, allergic rhinitis, and eczema is known as the atopic triad an occurs in 80% of patients.

Eczema in children

Erythema and scaling of cheeks. Can progress to face, neck, forehead, and extremities. Pustules can form from itching.

Eczema in adults

usually less severe. Elbow, behind the knees, forehead.

Acute Eczema

Intense itching and papules or vesicles often associated with secretions

Subacute Eczema

Dry, scaly, papules, and plaques

Chronic Eczema

Lichenification

Clinical presentation of Eczema

Itchy rashes, dry and discolored skin, repeated itching leads to lichenification.

lichenification

Thickened plaques of skin with accentuation of normal skin markings. Plaques are red, scaly, exudative, and or crusty.

Exclusions for Eczema

Moderate-severe with intense itching, involvements of large area of the body, <1 years old, signs of infection, face or skin folds involved, no improvement or worsening after 2-3 days of treatment

Eczema Non-pharm

avoid triggers, use unscented products, limit duration and temperature of bathing, avoid allergens, wear cotton gloves, keep fingernails short, prioritize skin hydration

Topical Corticosteroids for Eczema

Suppress cytokines involved in the development of inflammation and itching. Avoid in areas of cracked or infected skin. Not for children <2 or for more than 7 days.

Oral Antihistamines for Eczema

Not recommended for routine treatment, may help with sleep

Wet wraps for Eczema

Use with a steroid or emollient. Wrap them with a wet cloth and then a dry cloth.

Contact dermatitis

Irritant contact dermatitis or allergic contact dermatitis. Inflammation, redness, vesicle, and pustule formation. ICD is usually dry, cracked, and inflamed skin along with itching, burning, and stinging. No family history or linked to other conditions.

Irritant contact dermatitis

Can be occupational, exposure to water or irritant substances. Usually in delay in onset of symptoms. Inflammation, swelling, and erythematous. Itching, burning, and stinging associated with rash. Can be on the hands and arms. Usually, no vesicles or papules but can occur in the confined area. Not immune related.

ICD Treatment

Remove irritating agent, wash exposed area with mild soap. Use Burrow’s solution, emollients (Aquaphor), barrier creams (petroleum)

Burrows solution

Domeboro. Dissolve packet in cool water, shake to dissolve, refrigerate, and soak the area for 15-30 minutes.

Poison Ivy Clinical Presentation

Urushiol enters skin within 10 minutes. Is easily transmittable to other areas of the body or the others due to transfer. Rash occurs 24-48 hours after contact but can occur after a few hours. Intense itching followed by erythema and vesicle and bullae formation. Final stage is crusting and drying.

Exclusions for allergic contact dermatitis

<2 years of age, >20% of body surface area, numerous large bullae, extreme itching, irritation, or discomfort, mucous membranes, eyes, eyelids, and genitalia, signs of infection, symptoms for >1 week, impairment of daily activities, face, neck, or scalp is involved.

Poison Ivy treatmment

Wash contaminated clothes separately, wash exposed area within 30 minutes, use a post-exposure treatment, Lukewarm showers, oatmeal baths, calamine lotion for itching, avoid topical antihistamines. Refer after one week.

Hydrocortisone 0.5-1%

Cream that allows weeping lesions to dry. Avoid ointments in in weeping vesicles or bullae. Use 3-4x a day.

Neurodermatitis

Usually confined to 1-2 patches of skin, can occur anywhere you can scratch, begins with an itch from something and then into a cycle of intense itching. Stress and anxiety can be triggers. Common in women and people with anxiety disorders.

Dyshidrotic Eczema

Small, itchy fluid filled blisters. Palms of hand, soles of feet and edges of fingers and toes. Also called pompholyx and food and hand eczema. Metals like nickel are common triggers.

Nummular eczema

Scattered circular itchy oozing patches. Common on arms and legs. Difficult to diagnose due to similarities between other types of eczema and ringworm. Stress is a common trigger.

Dandruff

Small white flakes from scalp scaling. Minimal inflammation and erythema. Due to accelerated cell turnover. Involves presence of the yeast Malassezia. Selenium sulfide or pyrithone zinc shampoo can be used to help. Leave on hair for 3-5 minutes. Use daily for 1 week and hen 2-3 times per week. Nizoral shampoo is another option.

Seborrheic Dermatitis

Common on the scalp and other areas with sebaceous glands such as the face, sides of the nose, eyebrows, ears, eyelids, and chest. Scaly patches, red skin, and dandruff. Cradle Cap.

Seborrheic dermatitis treatment

IN adults used medicated shampoos like Nizoral daily for the first week then 2-3x a week. For babies massage their heads with baby oil and then a gentle shampoo to remove the scales.

Stasis dermatitis

From venous insufficiency. Usually in feet or lower legs. Causes ankle swelling, orange and brown discoloration. Hot itchy spots, dry, scaling, discolored.

Treatment Goal for Insect Bites

Relieve symptoms and prevent secondary bacterial infection. Monitor bites and prevent future bites.

Exclusions for Insect Bites

Hypersensitivity to insect bites resulting in systemic symptoms or symptoms away from the insect bite. <2 years of age, history of tick bite and systemic effects indicating infection present, suspected spider bite, suspected scabies, signs of secondary infection.

Avoiding Insect bites

Cover skin and cuff clothing, avoid dense woods or areas that harbor bugs, keep pet’s pest free, remove standing water, limit time spent outside at dusk-dawn, use barrier such as screens and netting, for bed bugs do not put clothes on carpets or chairs, keep things off the floor and bed.

DEET

Most effective all purpose repellent, dose not kill only repels insects, applied every 4-8 hours, children <2 months do not use more than 30%, 50+ has no great benefit but may last longer, rare CNS reaction can occur, do not combine with sunscreen.

Other insect repellents

Citronella, Eucalyptus, lavender, tea tree, garlic, Picaridin, permethrin is designed for clothing and camping equipment.

Local Anesthetics

Caines, relieve itching and irritation, may apply 3-4x a day up to 7 days, allergic reactions possible, do not occlude phenol or apply a lot. For >2 years old.

Topical Antihistamines

For >2. Diphenhydramine HCL, may apply 3-4x up to 7 days, helps pain and itching. Depresses cutaneous receptors

Counterirritants

>2. Camphor and menthol. 3-4x a day up to 7 days. Relieve itching and irritation, “cooling”

Skin protectants (insect bites)

May be used to reduce irritation or inflammation and can absorb weeping fluids. May be used < 2 years old. As needed up to 4x a day. Products like calamine or zinc oxide. Seek medical attention if condition worsens after 7 days.

Insect sting general approach

Remove the stinger, ice in 10-minute intervals, apply antiseptic

Exclusion for insect stings

hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing, signs of allergic reaction, previous sting by honeybee, wasp, or hornet, previous severe reaction, personal or family history of reaction, <2 years old.

Avoiding insect stings

Avoid wearing perfume, scented lotions, or brightly colored clothes. Control odors in picnic and garbage areas. Change kid’s clothes if contaminated with food, wear shoes, destroy nests near home, if sensitive carry something that shows the nature of the allergy.

Lifecycle of head lice

Spread with head-to-head contact. Louse requires meal within 24 hours of hatching. Females live for one month and lay 7-10 nits a day which will hatch in 8-10 days. They take 8-9 days to mature. Bites create a wheal and papule causing itching.

Exclusion for Lice

hypersensitivity to chrysanthemums, rag weed, or pediculicide. Presence of secondary skin infection, <2 years old for pyrethrins, <2 months old for permethrins, lice infestation of eyebrows or eyelids, pregnancy or breast feeding, regional resistance, presence of active tumors.

Non pharm lice treatment

AirAlle- heats the head and kills lice and nits, expensive and needs a tech, avoidance of direct physical contact, wash clothing and bedding in hot water and clothes dryer, seal things in plastic bags, vacuum regularly.

Pyrethrins

Approved for head and pubic lice, limits the ability of lice to breakdown pyrethrin, kills louse not eggs. Low toxicity if used as directed but can cause some irritation.

Permethrin

Comes in a cream. Kills the louse not the eggs, can cause irritation and itching. More effective than pyrethrin after one application.

Pyrethrin product directions

Applied as a shampoo, foam (dry hair), solution, or gel, applied to affected area for ten minutes then rinsed. Must follow up with lice comb. May repeat in seven to ten days to kill remaining nits that may have hatched. Do not apply more than two times in a day.

Permethrin product directions

Applied to washed towel dried hair. Saturate hair and scalp, leave on hair for ten minutes then rinse. Must comb with lice comb. Crease rinse has effects up to ten days.

Ivermectin

Nit combing is not necessary but may want to do for cosmetic reasons. For ages 6+, applied to dry hair start at scalp and work your way back. Thoroughly coat the scalp and head. Wait ten minutes. Rinse hair to remove lotion, discard excess lotion, do not shampoo 24 hours.

Natrum muriaticum

Sodium chloride solution which dehydrates lice and eggs. Apply to dry hair and comb with nit comb

Alternative Lice therapies

Not FDA approved lice enzyme shampoo, tea tree oil, battery operated combs

DSP

Dry on suffocation pediculicide. New therapy, applied to hair and dried to the head to suffocate lice. Made of 100% dimethicone gel.

UVA

penetrates deep into the dermis and is the common cause of aging like fine lines, wrinkles, and sagging

UVB

Mainly affect epidermis leading to sunburns, tanning, and skin cancer

Sunburn

Is an inflammatory process that range in severity.

Sunburn risk factors

Fair skin, history of sunburns, light hair/eyes, freckles, previous growth caused by UV exposure, family history of melanoma, immunosuppressant drugs, photosensitizing drugs, excessive UV exposure, history of autoimmune disease

Non Melanoma Skin Cancers

Majority found in areas with high sun exposure like the face, neck, and back of hands

BCC= waxy/pearly with a sunken center

SCC=Raised, dull red lesion, thick crusted scale, ulcerated appearance

Melanoma Risk Factors

Family history, sun sensitivity, tanning bed use, history of excessive sun exposure.

ABCDE method

Asymmetrical, Border, Color, Diameter, Evolution

SPF

Sun protection factor measured by number. Derived from dividing the minimal erythema dose on protected skin by the MED on unprotected skin. SPF based on formulation not ingredients.

Broad Spectrum Sunscreen

Must be at least 15 and have both UVA and UVB protection.

FDA SPF Proposed Rules

Can not market SPF <2 or >60. >15 must be broad spectrum. Chemical sunscreens technically not evaluated. Mousse and foams are not FDA approved.

Sunscreen Selection

15 for everyone more than 30 for those at risk. If acne prone choose one that is noncomedogenic. Water resistant if very active.

Physical sunscreeen

Barrier on the skin to reflect rays, thicker consistency, preferred in sensitive skin and children.

Chemical Sunscreen

Absorb into skin, lighter texture and less greasy, do not leave a white cast on the screen, more water and sweat resistant

Sunscreen application

1 ounce or the amount you can hold in your palm to cover your whole body. Apply liberally. ½ teaspoon everywhere, 1 teaspoon on legs. Wait 15-30 minutes for effect before sun exposure.

Wounds

Break in the skin, abrasions are from rubbing or friction, lacerations are cuts or punctures

Treatment goals of wounds

Relieve symptoms, promote healing, minimize scaring, pain control.

Wound assesment

Cause, timing, size, depth. Burns should be reassessed in 24-48 hours.

Burn care

Cool tap water within 1st 20 minutes, benefits up to 3 hours after burn. No Ice or ice water the vasoconstriction can result in further tissue damage. Clean wound with clean water or saline, do not pull loose skin or pop blisters.

Wound dressing

Moist wound environments are good to reduce scarring, all superficial partial thickness burns should be covered.

Hydrocolloid dressings

Form a moist healing environment. Good for partial thickness wounds with minimal or moderate exudate. Also good for blisters and minor burns.

Tegaderm

Transparent adhesive film. Waterproof. Moist healing environment, not for heavy exudate, good on joints, stays on for 4-7 days.

liquid adhesive bandage

Spray or brush. Not for large areas. Preferred for high visibility areas.

Scaring

Best therapy is silicone. Mederma has onion extract.

Pharm therapy for wounds

Systemic analgesics, antibiotic ointments, skin protectants, topical anesthetics

Comedone

Small bumps on the skin caused by clogged pores. Blackheads or whiteheads.

Comeodolytic

Lysis of comedones, decreases comedones

Keratin

Fibrous protein in the skin, hair and nails, too much causes patches of rough bumpy skin

Keratolytic

Lysis of keratin, smoothing of skin

Sebum

The oily substance produced in the sebaceous glands

Causes of acne

Sebum production by sebaceous gland, follicular colonization by cutibacterium acnes, alteration of the keratinization process, release of inflammatory mediators in the skin

Non inflammatory regions

Open comedones: black heads, open to air

Closed comedones: white heads, pore remains covered

Inflammatory lesions

Papule: Redness and inflammation

Pustule: redness, inflammation, purulento in center of lesion

Acne triggers

Stress, hormones, high glycemic foods, dairy, chocolate, genetics, sleep patterns

Drug induced Acne

Anabolic steroids, bromides, corticosteroids, corticotropin, isoniazid, lithium, phenytoin, cyclosporine, quinidine, tetracycline

Mild acne

Few erythematous papules and occasional pustules mixed with comedones