Dermatitis

State the general features, signs and symptoms, and risk factors for the development/exacerbation of atopic and contact dermatitis

• Atopic Dermatitis

  • General Features

    • Inflammatory condition: episodic flares with periods of remission

      • Epidermis and dermis

    • Often seen with asthma and allergic rhinitis “atopic triad”

    • Most instances of AD are relatively mild can be self treated in persons >2 years of age

  • Signs and symptoms

    • Young age (2-3 months to 5 y/o)

    • Erythema and scaling on facial cheeks

      • Can spread to rest of the face, neck, extremities 

    • Crust, pustules (esp with scratching, rubbing)

    • Often less severe in adults

      • Behind the knees, neck, hands

      • Environmental triggers (chemicals, skin trauma)

    • Pruritus is hallmark symptom → itch-scratch cycle

      • Plaque development (lichenification)

      • Exoriation 

  • Risk factors

    • Genetic basis

    • Climate, urbanization, diet, pollution/tobacco smoke

    • Asthma, allergic rhinitis, food allergies

    • Alternations in gut and skin microbiome

• Contact Dermatitis

  • General features

    • Two types:

      • Irritant CD (ICD)

      • Allergic CD (ACD)

        • Immunological rxn caused by exposure to an allergen

  • Signs and Symptoms

    • Inflammation

    • Erythema

    • Pruritis

    • Burning/Stinging

    • Vesicle, bullae, pustule formation

  • Risk factors

    • ICD:

      • Single exposure or multiple exposures with an irritant

        • Harsh chemicals vs mild detergents 

        • Disruption of skin barrier, release of inflammatory markets

      • Magnitude of response is magnified by:

        • other skin conditions (atopic dermatitis)

        • quality/concentration of substance

        • Ambient temperature, humidity

    • ACD:

      • Primary causes:

        • Poison ivy

        • Poison oak

        • Poison sumac

Differentiate between the presentations of atopic and contact dermatitis, when self treatment is indicated and appropriate, and when patients need to be referred for further care

• Atopic Dermatitis Presentation

Type of AD	Presentation
Acute AD	Intense pruritus Erythematous papules or vesicles Erythematous skin Excoriation and exudation
Subacute AD	Erythematous excoriated papules and plaques; scaly
Chronic AD	Lichenification and accentuated skin markings

• Referral for AD:

  • Moderate - severe condition with intense pruritus

  • Involvement of large area of the body

  • Involvement of the face or in intertriginous areas of the body

  • < 1 year old

  • Presence of skin infection

    • S. aureus, S. epidermidis, C. bovis, C. mastitidus

    • Viruses (rare)

• Contact Dermatitis

Type of CD	Presentation
Irritant CD	Reactions appear on exposed skin surfaces Face Intertriginous spaces on hands Top of hands, forearms Chronic exposure may lead to  Pigmentation changes Necrosis of skin
Allergic CD	Mild: Localized rashes in unprotected/exposed areas, pruritic, linear streaks from scratching Moderate vesicles/bullae, edema in addition to pruritus, erythema, inflammation  Severe: Severe edema to extremities or face, closure of eyelids, larger vesicles/bullae, large areas of body effected

• Referral for CD:

  • < 2 years old

  • Dermatitis present for > 1 week; chronic

  • Symptoms develop after sun exposure

  • > 10% BSA effected (ICD); > 20% BSA effected (ACD)

  • Severe symptoms: itching, numerous large

  • vesicle/bullae formation, edema

  • Involvement of genitalia, mouth, eyes/eyelids, nose,

  • anus, face, scalp, neck

  • Secondary infection present

  • Failure of self-care after 7 days

  • Impairment of ADLs

Identify lifestyle modifications/nonpharmacologic therapies that may relieve atopic and contact dermatitis

• AD Nonpharmacologic Therapy

  • Consider patient specific factors 

    • Identify and eliminate triggers

  • Humidifiers

  • Avoid sudden changes in temp and humidity

  • Short, clean fingernails

  • Cotton sheets and clothing; laundering thoroughly new sheets and clothes

  • Bathing in lukewarm water, hypoallergenic/fragrance-free soaps (ex. Dove)

  • Emollients for moisturizing (BID); esp after bathing

  • Diluted bleach bath (children)

    • BID

    • Recommended with recurrent skin infections

    • ½ cup bleach per 40 gallon of water (full bathtub)

  • Wet wrapping

    • Moisten the dressing in warm water until slightly damp

    • Wrap the moist dressing around the affected area

    • Wrap a dry dressing over the wet one

    • Carefully put on nighttime clothing so as not to disturb the bandages

    • Leave bandages on for several hours or overnight

• CD Nonpharmacologic Therapy

  • ICD

    • Wash the area with copious amounts of tepid water

    • Cleanse with either 

      • Mild or hypoallergenic soap (Cetaphil, Dove) or 

      • Saline soak (1 tsp salt in 1 pt water)

  • ACD

    • Make/use flashcards to quickly and accurately identify suspicious plants

    • Wear protective clothing to prevent accidental contact

      • Long sleeve

      • Long pants

      • Hiking boots

      • Hats

    • Wash AA with mild soap and water immediately after, efficacy seen up to 30 min

    • Clip fingernails 

    • Avoid vigorous scrubbing or use of harsh scrubbers

    • Wash contaminated clothing

      • Remove affected clothing

      • Wash separate from other clothes

      • Use regular detergent

    • Showering is beneficial to relieve pruritus

      • Cold or tepid temperatures

      • Hypoallergenic soap

      • Scrub under fingernails

    • Avoid bathing

Compare and contrast nonprescription products for the prevention and treatment of atopic and contact dermatitis and describe their MOA’s, application/use/directions, ADR’s and pertinent patient counseling information

• AD Pharmacologic Therapy

  • Corticosteroids

    • Anti-inflammatory drug for acute flare-ups

    • Hydrocortisone cream is general DOC

    • Ointment is preferred for thickened, dry or scaly skin

    • Apply BID sparingly during flares

    • Safe for use on most body locations in persons >2 years of age

    • Risk of tachyphylaxis

      • Use once or twice weekly during remission

    • Avoid when:

      • AD lesions are weeping (ointment formulations)

      • Skin is infected, cracked, open

      • Refractory cases

  • Antihistamines

    • Can relieve pruritus; topical diphenhydramine often used

    • Cooling effect from base; potential risk of contact dermatitis

    • Oral diphenhydramine not recommended

      • Lack of efficacy 

      • Increased sedation but can help w/ sleep w/ excessive scratching

• CD Pharmacologic Therapy

  • ICD:

    • Liberal application of emollients/moisturizers to affected area

      • Restore moisture

      • Repair skin barrier 

      • Protect area

    • Skin protectants

      • Prevent water loss

      • Increase skin hydration

    • Colloidal oatmeal baths for itching

    • Topical corticosteroids (avoid use)

      • Reduce inflammation, pruritus, irritation

      • Lack of evidence to use for ICD

      • May increase risk of ICD with chronic use

  • ACD:

    • Bentoquatam 5% lotion: Prevention of Poison Ivy/Oak/Sumac

      • MOA: binds to urushiol and blocks absorption

      • ADR

        • Faint white coloring on skin

        • Erythema

        • Minor skin irritation

      • Pt Counseling

        • Apply to clean, dry skin at least 15 min before exposure risk

        • Let dry

        • Reapplication necessary after 4 hours

      • AVOID:

        • Topical anesthetics, antihistamines, antibiotics

    • Untreated or treated: most resolve in 10-21 days

    • Topical Skin Cleansers

      • Tecnu Outdoor Skin Cleanser

        • Removes urushiol that has bound to the skin

        • Effective up to 8hrs after urushiol exposure; may also use after rash formation

        • Minimum contact time with skin: 2 minutes

        • Reapply PRN

      • Zanfel Poison Ivy Wash

        • Removes urushiol that has bound to skin

        • Effective at any point after urushiol contact

        • Wash AA until pruritus resolves

          • 75-80% of rash should resolve within 24hr

        • Second application may be necessary if pruritus returns

    • Astringents

      • Useful in reducing oozing/weeping of vesicle fluid

      • Promotes drying of lesions

      • Reduces edema

      • Cleanses skin

      • Mildly antipruritic 

        • ex) aluminum acetate 1:40 (burrows solution

        • Witch hazel

    • Skin protectants

      • MOA: forms barrier over skin which facilitates healing

        • Absorbs fluids from oozing/weeping lesions

      • Product examples

        • Oatmeal

        • Zinc Oxide

        • Titanium dioxide

        • Calamine lotion

      • Apply PRN to AA

    • Topical corticosteroids

      • DOC: Hydrocortisone 0.5-1% cream TID to QID x7days

      • Avoid use:

        • Over large surface areas, eyes/eyelids

        • Occluding skin

        • Prolonged use

        • Over broken skin