DEENT Exam 2

The epidermis is the first ___ layers of the skin

four

What layer of the skin are you typically treating when you treat dermatitis?

epidermis

What is typically used when treating dermatitis?

topical creams and ointments

Topical medications are often the most ____ in standard tube sizes

cost-effective

Perscribed amounts are ___ to available tube sizes

rounded up

How much is a fingertip unit?

0.5g

How many fingertip units are used on the scalp?

3 (1.5g)

How many fingertip units are used on the face and neck?

2.5 (1.25g)

How many fingertip units are used on hand (front and back, including fingers)?

1 (0.5g)

How many fingertip units should be used for one arm, including the entire hand?

4 (2g)

How many fingertip units should be used for the elbows?

1 (0.5g)

How many fingertip units should be used for both soles of the feet?

1.5 (0.75g)

How many fingertip units should be used for one foot, including toes?

2 (1g)

How many fingertip units should be used for one leg, including the foot?

8 (4g)

How many fingertip units should be used for the buttocks?

4 (2g)

How many fingertip units are used for the knees?

1 (0.5g)

How many fingertip units are used for both sides of the trunk?

14 (7g)

How many fingertip units are used for one side of the trunk?

7 (3.5g)

What is the hallmark symptom of atopic dermatitis?

Pruritis

Atopic dermatitis is usually due to what?

allergen influx, especially due to broken or damaged skin barriers

Atopic dermatitis is also known as what?

eczema

Atopic dermatitis is a very ______ inflammatory skin disorder with typical morphology and age-specific patterns

common chronic or relapsing

When does atopic dermatitis often develop?

childhood

There is no __ for AD and it is not ___

there is no cure for AD and it is not contagious

Emollient therapy improves the skin barrier to block what?

the inflammatory cascade

What is the atopic triad?

Allergic Rhinitis (Hay Fever), Asthma, and Atopic Dermatitis

What is the atopic march?

Refers to the natural history or typical progression of allergic diseases that often begin early in life

What puts someone at risk for AD?

personal or family history of atopic disorders

loss of function mutation of the FLG gene

living in an urban environment

smaller family size

higher level of parental education

What irritants may trigger AD?

Airborne - tobacco smoke, air pollution

Cosmetics, fragrances, astringents

Irritating soaps/scrubs/detergents

Dyes /preservatives

What allergens may trigger AD?

Food: Eggs, milk, peanuts, soy, wheat, nuts, tomato

Clothing: Wool, polyester

Aeroallergens: House dust mites, Pollens, Pet dander, Mold

What environmental factors might trigger AD?

Extreme temperatures and Low Humidity

What personal factors trigger AD?

Stress

Excessive skin washing and sanitizing

ASWQHow does AD present in infants (0-2)?

Quality/Quantity: Erythematous, popular rash that tends to ooze

Region: Face, scalp, trunk, arms, and legs

Timing: Most common onset is between 3-6 months of age

The majority have onset by age one

How does AD present in childhood (2-puberty years)?

Quality/Quantity: Dry, flaky, rough, cracked skin, crusting, lichenification

Region: Face, creases of the neck, elbows, wrists, knees, ankles

Timing: Up to 90% by age 5 years old

How does AD present in adulthood?

Quality/Quantity: More diffuse with underlying erythema, dry, scaly skin, lichenification

Region: Less common on the face and more common on the hands, neck, inner elbows, back of knees, and ankles Timing: May have resolution of disease by adulthood (70-90%)

What is lichenification?

Skin is dark and thick with plaque, dry, flaky skin that is clumped together. Typically seen in adult patients, but can be seen in children.

How does age of onset predict the persistence of AD?

Patients with early onset of the disease will most likely have it throughout life, and patients with late onset have decreased persistence

What is the SCORAD scale?

Clinical tool used to assess the extent and severity of AD (SCORing Atopic Dermatitis)

On the SCORAD scale what is classified as mild?

less than 25

On the SCORAD scale what is classified as moderate?

25-50

On the SCORAD scale what is classified as severe?

greater than 50

What characteristics classify a mild case of AD?

Areas of dry skin, infrequent itching (with or without small areas of redness); little impact on very day activities, sleep, and psychosocial wellbeing

What characteristics classify a moderate case of AD?

Mild characteristics with frequent itching, moderate impact on everyday activities, and sleep

What characterisitics classify a severe case of AD?

Wide-spread areas of dry skin, incessant itching, redness, thickening, bleeding, oozing, severe limitation to activities, and nightly loss of sleep

How are acute lesions characterized?

acutely inflamed papules, vesicles, exudate, and crisis

How are subacute lesions characterized?

dry and inflamed

How are chronic lesions characterized?

lichenified plaques

What are some complications associated with AD?

sleep disturbances, impact quality of life and family's quality of life, skin infections, and depression

What skin infections are associated with AD?

S. aureus

Prone to infections with herpes simplex virus

Atopic dermatitis treatment goals

Eliminate triggers

Reduce symptoms

Prevent future flare-ups

Prevent secondary infections

Minimize adverse drug reactions

Reduce trans-epidermal water loss

You shouldn't use oral or topical antibiotics over what?

large areas of skin

How do you avoid stripping off the weakened epidermis?

Use gentle cleansers and limit bath time (bath water should not be too hot or too cold)

How do you help reestablish the epidermis?

moisturize with thick emollients and maintain hydration

How do you reduce inflammation when treating AD?

Use topical medications to reduce inflammation and decrease scratching

Atopic dermatitis bathing practices

Suggest a 10-minute lukewarm bath with gentle cleansers and then pat dry gently. Patients may add oatmeal or baking soda to bath water daily. After bathing, an occlusive moisturizer should be applied to decrease moisture release.

In severe cases patients can add what to their bath water?

May add bleach (0.005% Na hypochlorite = ½ cup bleach to full tub of water) twice a week, to prevent recurrent bacterial skin infections

What is the purpose of applying occlusive moisturizers immediately after bathing?

trap moisture and strengthen the skin barrier

What non-pharmacological treatments can be used to treat AD?

bathing practices, gentle cleansers, wet wrap, soft cotton clothing, avoiding unknown triggers, and decreasing stress

What is a wet wrap?

You wrap the skin in a gauze rag to trap moisture in, but it cannot be used with calcineurin inhibitors

OTC moisturizers: Petroleum-containing

Comments: Occlusive, greasy, can be uncomfortable

Examples:

- Aquaphor: Petrolatum

- Eucerin: Petrolatum, mineral oil

- Lubriderm: Mineral oil, lanolin, petrolatum

OTC moisturizers: Ceramide-containing

Comments: creams, provides barrier

Examples:

- CeraVe: glycerin, petroleum,ceramides, hyaluronic acid, etc

- Aveeno eczema therapy: Oatmeal, ceramides

OTC moisturizers: Urea-Containing

Examples: Carmol 10% ,20% and Lac-Hydrin 5%

Comments: Humectant

Side effects: burning, stinging, irritation on broken skin due to its acidic properties

OTC moisturizers: Emollients

Examples: Cetaphil Lotion, Keri Original, Neutrogena Lotion

Comments: Less effective and apply 3 x /day or more, after bathing/washing

What type of OTC moisturizer provides the best barrier?

Petroleum, while it may be greasy it has the best occlusive properties

When should a patient be referred to a physician for treatment of their AD?

If symptoms do not improve or worsen within 2-3 days of self treatment or if atrophy of the skin or infection while using a topical steroid occurs

What is the mechanism of action of topical corticosteroids?

When we give a steroid, it is always carried around the body by a protein. The glucocorticoid-binding globulin is what carries the steroid. The drug is carried around in our blood and then is eventually able to enter the cell. Once it enters the cell, it binds to the nuclear receptor. When any of our nuclear receptors are floating around in the cytosol, they are being chaperoned by other proteins and cannot be alone. The NR is chaperoned under it runs into the steroid, which then binds together, resulting in a steroid/receptor pair. The pair will find another steroid receptor pair and dimerize. They have to dimerize to be able to move into the nucleus and sit down on the glucocorticoid response element and affect gene transcription. This is the direct mechanism of a steroid.

Topical corticosteroids indication

Corticosteroid-responsive dermatoses, Anal genital pruritus, Hemorrhoids, Ulcerative colitis

Topical corticosteroids ADR

Skin burning, tingling, cracking, pruritus, acne, alopecia, headache, skin atrophy, delayed wound healing

Topical corticosteroids contraindications

Hypersensitivity to steroids, systemic fungal infections, obstruction, abscess, peritonitis,and treatment of diaper dermatitis

Topical corticosteroids pharmacokinetics

Absorption: varies depending on age, skin integrity, thickness of skin, and anatomic location

Topical corticosteroids counseling points

-Apply to clean and dry area

-Apply a thin layer and rub in gently until medication vanishes

-Store in a cool, dry, room temperature location

-Do not apply for longer than 2 weeks

What is the first line therapy for AD?

topical corticosteroids

What are the key guidelines for using topical hydrocortisone 1% for skin flare-ups?

Potency: Low to medium; safe for body and always used for the face.

Application: Apply twice daily for a maximum of 3–7 days, or until the flare-up clears.

Precautions:

If not resolved after 7 days, seek medical advice.

Do not use longer than 2 weeks.

In general, topical corticosteroids should not be used longer than what?

14 days but medical advice should be sought out after 7 days of use if there is no resolution

Steroid vehicle influences what?

the strength of the medication

Dosage forms in order of highest to lowest topical corticosteroid

Ointment > Creams > Lotions > Solutions > Gels > Sprays

Clobetasol Propionate 0.05% ointment, cream, or foam is a ___ potency topical corticosteroid

very high

Betamethasone dipropinate 0.05% cream, ointment, foam, solution is a ___ potency topical corticosteroid

high

Flucocinonide 0.05% cream, gel, ointment, solution is a ___ potency topical corticosteroid

high

Mometasone furoate 0.1% ointment is a __ potency topical corticosteroid

high

Mometasone furoate 0.1% cream is a ___ potency topical corticosteroid

medium

Triamcinolone acetonide 0.1% cream/ointment is a ___ potency topical corticosteroid

medium

Which topical corticosteroid is the lowest potency?

Hydrocortisone

Hydrocortisone 1% is available ___

OTC

What is the second line treatment option for atopic dermatitis?

Calcineurin inhibitors

Calcineurin inhibitors MOA

Action: Inhibit activation of T cells and mast cells → block production of proinflammatory cytokines and mediators

Effect: Reduce the extent and severity of symptoms

Note: Acts as an immunosuppressant

CD4⁺ T-Cell Activation & Calcineurin Inhibitors

Signal 1: APC presents antigen on MHC II, binding to T-cell receptor (TCR) → antigen recognition.

Signal 2 (Co-stimulation): APC CD80/86 binds CD28 on T-cell → activates intracellular signaling → calcineurin activates NFAT, which triggers IL-2 gene transcription.

Signal 3: Secreted IL-2 binds IL-2 receptor (CD25) on the same T-cell → drives T-cell proliferation and clonal expansion.

Calcineurin inhibitors (e.g., cyclosporine, tacrolimus):→ Block calcineurin, preventing NFAT activation → no IL-2 transcription → suppressed T-cell activation and immune response.

What is the indication for topical calcineurin inhibitors?

Mild-moderate AD, second line treatment

What ADRs are associated with topical calcineurin inhibitors?

skin burning, tingling, cracking, pruritus, coughing, and flu-like symptoms

Calcineurin inhibitors should ONLY be used as what?

Second-line treatment for a short, intermittent period of time

Calcineurin inhibitors are contraindicated with what?

Hypersensitivity to calcineruin inhibitors or any component of the formulation

Calcineurin inhibitors cannot be used in children under what age?

2

How should you counsel a patient on using calcineurin inhibitors?

-Apply to clean and dry area

-Apply a thin layer and rub in gently until medication vanishes

-Do not bathe, shower, or swim right after application

-Store in a cool, dry, room temperature location

-Do not use in children < 2 years of age

-Response in weeks, continue to apply (1-8 weeks)

What are the two topical calcineurin inhibitors?

Pimecrolimus and Tacrolimus

What is the brand name for pimecrolimus?

Elidel

What is the brand name for tacrolimus?

Protopic

What are pimecrolimus (Elidel) and tacrolimus (Protopic) used to treat?

mild to moderate eczema in children 2 years of age or older and adults

Pimecrolimus (Elidel) reduces the incidence of __

flares

What dosage form does Pimecrolimus (Elidel) come in?

1% cream that is applied to the affected area twice a day

What dosage form does tacrolimus (Protopic) come in?

ointment