Presentation is loading. Please wait.

Presentation is loading. Please wait.

Eczema, Two Thousand Rashes and Three Creams A Dermatology Primer for Mid Level Practitioners Mid Level Practitioners.

Similar presentations


Presentation on theme: "Eczema, Two Thousand Rashes and Three Creams A Dermatology Primer for Mid Level Practitioners Mid Level Practitioners."— Presentation transcript:

1

2 Eczema, Two Thousand Rashes and Three Creams A Dermatology Primer for Mid Level Practitioners Mid Level Practitioners

3 Critical components of the physical exam of the skin should include: Type Type Color Color Shape Shape Arrangement Arrangement Duration Duration Distribution Distribution

4 Adequate history should include: Skin symptoms Skin symptoms Constitutional symptoms Constitutional symptoms Travel/Occupation Travel/Occupation Systems review Systems review Self care Self care

5 Types of lesions Macule Macule Papule-plaque Papule-plaque Wheal Wheal Nodule Nodule Cyst Cyst Vesicle-bulla Vesicle-bulla Ulcer Ulcer Pustules Hyperkeratosis Exudative: dry/wet Erosion Scar Lichenification

6 Shapes of Lesions The shape of a lesion frequently gives clues to the etiology of the skin lesion. The shape of a lesion frequently gives clues to the etiology of the skin lesion. Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous, umbilicated,and target. Shapes include lesions that are: round, polygonal, polycyclic, annular, iris, serpiginous, umbilicated,and target. Margination is also important – are the lesions well or ill defined Margination is also important – are the lesions well or ill defined Arrangement – are the lesions grouped or disseminated Arrangement – are the lesions grouped or disseminated

7 Distribution of Lesions A significant number of skin diseases are limited to specific regions of the body A significant number of skin diseases are limited to specific regions of the body Are the lesions isolated, localized, regional, or generalized Are the lesions isolated, localized, regional, or generalized Are the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas Are the lesions symmetrical; limited to exposed areas, sites of pressure, or intertriginous areas

8

9 Eczema - Common Definitions Any itching rash Any itching rash Any red itching rash Any red itching rash Any red itching rash that has scales or is dry Any red itching rash that has scales or is dry The itch that rashes The itch that rashes Any rash that cannot otherwise be identified Any rash that cannot otherwise be identified

10 Eczema-Dermatological Definition An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 1 An acute, subacute but usually chronic pruritic inflammation of the epidermis and the dermis, often occurring in association with a personal family history of hay fever, asthma, allergic rhinitis or atopic dermatitis. 1 1 Color Atlas and Synopsis of Clinical Dermatology 1 Color Atlas and Synopsis of Clinical Dermatology

11 Characteristics of Acute Eczema Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crusting Well demarcated plaques of erythema and edema on which are superimposed and closely spaced small vesicles filled with clear fluid with punctate erosions and crusting Distribution may be isolated and localized or general Distribution may be isolated and localized or general

12 Acute Eczema ( Note the erythema, vesicles and swelling) Term dyshidrotic is a misnomer as sweat glands are not involved Term dyshidrotic is a misnomer as sweat glands are not involved Also known as pompholyx Also known as pompholyx

13

14 Characteristics of Subacute Eczema Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papules Plaques of mild erythema with small dry scales and or superficial desquamation, sometimes associated with small red, pointed or round papules Distribution may be isolated and localized or general Distribution may be isolated and localized or general

15 Subacute Eczema Note erythema, swelling and desquamation Note erythema, swelling and desquamation

16 Characteristics of Chronic Eczema Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythema Plaques of lichenification with deepening of the skin lines with satellite, small, firm flat or round top papules, excoriations and pigmentations or mild erythema Distribution – isolated and localized or generalized Distribution – isolated and localized or generalized

17 Chronic Eczema Note lichenification, scaling and fissuring Note lichenification, scaling and fissuring

18 Acute - Subacute - Chronic Swelling and erythema Punctate erythema, desquamation Lichenification

19 Acute, Subacute or Chronic? Check for erythema, swelling, desquamation, lichenification Check for erythema, swelling, desquamation, lichenification

20 Acute, Subacute or Chronic? Check for erythema, swelling, desquamation, lichenification Check for erythema, swelling, desquamation, lichenification

21 Classification of Eczema/Dermatitis Historically Endogenous (occurring from within) dermatitis was given the name “eczema” Endogenous (occurring from within) dermatitis was given the name “eczema” Exogenous dermatitis (occurring from without) was termed “dermatitis” Exogenous dermatitis (occurring from without) was termed “dermatitis”

22 Classifications of Eczema Endogenous Endogenous Atopic or IgE Atopic or IgE Seborrheic Seborrheic Discoid or nummular Discoid or nummular Pompholyx Pompholyx Venous Venous Asteatotic Asteatotic Juvenile plantar Juvenile plantar Erythoderma Erythoderma Exogenous Allergic Toxic irritant contact Photosensitive

23 Atopic/IgE Eczema (endogenous or exogenous?) Characteristics: 60% have onset in the first year of life 60% have onset in the first year of life Influenced by genetics and environmental factors Influenced by genetics and environmental factors More common in males that females More common in males that females Ethnicity may be a factor –less common in Asians; more common in Westerners and higher socioeconomic families Ethnicity may be a factor –less common in Asians; more common in Westerners and higher socioeconomic families Theory is - manifestation of well nourished immune system rarely challenged by infection Theory is - manifestation of well nourished immune system rarely challenged by infection Rare to have adult onset Rare to have adult onset 2/3 of patients have family history of asthma, hay fever or allergic rhinitis 2/3 of patients have family history of asthma, hay fever or allergic rhinitis

24 Characteristics: Characteristics: May persist months to years May persist months to years All patients have dry skin All patients have dry skin Exacerbations caused by allergens, stress, hormones, climate, skin dehydration Exacerbations caused by allergens, stress, hormones, climate, skin dehydration Physical characteristic may include all phases Physical characteristic may include all phases Distinctive Characteristics: Distinctive Characteristics: Lesions are usually bilateral Lesions are usually bilateral Located frequently in skin folds/creases and flexor surfaces Located frequently in skin folds/creases and flexor surfaces Atopic/IgE Eczema cont.

25 Atopic/IgE Eczema Distribution Note: Bilateral Skin folds and flexor surfaces

26 Atopic/IgE Eczema cont. Triggers:Irritants Dry skin; bathing without moisturizing Dry skin; bathing without moisturizing Harsh/perfumed soaps, detergents Harsh/perfumed soaps, detergents Disinfectants Disinfectants Contact with wool, occupational chemicals/fumes Contact with wool, occupational chemicals/fumesAllergens Dust mites Dust mites Pet dander (cat more allergenic than dog) Pet dander (cat more allergenic than dog) Pollens, seasonal and molds Pollens, seasonal and molds Foods- strawberries, carrots Foods- strawberries, carrots

27 Atopic/IgE Eczema cont. Triggers (cont’d): InfectionsBacterialViral 1. Cold and other URI viruses 2. GI viruses FungalEnvironmental Extremes in temperature and/or humidity PerspirationStress

28 Atopic/IgE Eczema cont. Confused with: Scabies, seborrhea, psoriasis and, contact dermatitis Scabies, seborrhea, psoriasis and, contact dermatitis

29 Atopic/IgE Eczema cont. Treatment: Treatment: Avoid scratching, clean and cool environment, use of soap substitutes Avoid scratching, clean and cool environment, use of soap substitutes Emollients Emollients Topical steroids Topical steroids Topical immunomodulators –tacrolimus Topical immunomodulators –tacrolimus Systemic antihistamines Systemic antihistamines Soaks Soaks Tar preparations Tar preparations

30 Atopic/IgE Dermatitis

31 Allergic (Contact)Eczema (exogenous or endogenous?) Characteristic: Delayed, cell mediated hypersensitivity Delayed, cell mediated hypersensitivity Strong sensitizer results in reaction soon after exposure Strong sensitizer results in reaction soon after exposure Weak sensitizer my take months or years to develop reaction Weak sensitizer my take months or years to develop reaction Age does not influence capacity for sensitization but more common in adults Age does not influence capacity for sensitization but more common in adults Black skin is less susceptible Black skin is less susceptible Important cause of disability in industry Important cause of disability in industry Non seasonal Non seasonal

32 Allergic (Contact) Eczema cont. Characteristics: usually clears quite rapidly on withdrawal of offending agent usually clears quite rapidly on withdrawal of offending agent may appear as erythematous papules, vesicles or bullous may appear as erythematous papules, vesicles or bullous more common where epidermis is thinner more common where epidermis is thinner Distinctive Characteristics: Initial lesions usually limited to contact area Initial lesions usually limited to contact area not bilateral not bilateral lesions with sharp borders or angles are pathognomonic lesions with sharp borders or angles are pathognomonic

33 Causes of Allergic/Contact Eczema Metals- nickel, platinum (10% of women) Metals- nickel, platinum (10% of women) Detergents Detergents Plants and fibers Plants and fibers Chemicals and dyes Chemicals and dyes Polyethylene glycol and polysorbate 60 Polyethylene glycol and polysorbate 60 Topical antibiotics and medications Topical antibiotics and medications Animal keratin Animal keratin

34 Allergic/Contact Eczema cont. Allergic/Contact Eczema cont. Treatment – remove causative agent, Burow’s soaks 1:40, or saline 1tsp/pt warm water, Aveeno or oatmeal baths, calamine Treatment – remove causative agent, Burow’s soaks 1:40, or saline 1tsp/pt warm water, Aveeno or oatmeal baths, calamine Systemic antihistamines Systemic antihistamines Topical steroids, oral steroid taper Topical steroids, oral steroid taper Antibiotics for secondary infection Antibiotics for secondary infection Confused with – Atopic eczema, seborrhea, HSV Confused with – Atopic eczema, seborrhea, HSV

35 Allergic/ Contact Eczema Distribution

36

37 Note: distribution

38 Note: Linear distribution with satellite lesions

39 What do you think?

40 Bilateral but…..

41 Subacute Allergic Eczema Note slight swelling and erythema Note slight swelling and erythema No lichenification No lichenification Location – what could be the cause? Location – what could be the cause?

42 Chronic Allergic Eczema Note the hyperkeratosis, lichenification and fissuring Note the hyperkeratosis, lichenification and fissuring

43 Toxic / Irritant Eczema (occurring in non allergic skin) Characteristics: Characteristics: Accounts for 75% of exogenous eczema Accounts for 75% of exogenous eczema Age, race and sex are insignificant Age, race and sex are insignificant Results from repeated exposure to toxic or subtoxic agents Results from repeated exposure to toxic or subtoxic agents Severity of skin symptoms vary with the individual and the type of irritant and the length of contact Severity of skin symptoms vary with the individual and the type of irritant and the length of contact Includes sx of itching, stinging and burning Includes sx of itching, stinging and burning Usually associated with chronic disturbance of the barrier function of the skin Usually associated with chronic disturbance of the barrier function of the skin

44 Toxic/Irritant Eczema cont. Common causes: Repeated exposure to alkaline detergents Repeated exposure to alkaline detergents Repeated exposure to organic solvents Repeated exposure to organic solvents Corrosive agents Corrosive agents Industrial chemicals Industrial chemicals Chronic self perpetuating habits that irritate the skin Chronic self perpetuating habits that irritate the skin

45 Toxic/Irritant Eczema cont. Treatment: Remove the cause Remove the cause Application of emollients Application of emollients Use of soap substitutes Use of soap substitutes Barrier creams Barrier creams Borrow’s or potassium permanganate soaks twice daily Borrow’s or potassium permanganate soaks twice daily Biopsy/testing- usually not necessary

46 Acute Toxic/Irritant Eczema Note: distribution, swelling and weeping

47 Subacute Toxic/Irritant Eczema Lip licking often seen in children who have atopic eczema often seen in children who have atopic eczema Variant of irritant eczema Variant of irritant eczema compare

48 Chronic Toxic/Irritant Eczema Note:papulosquamous dermatosis with hyperkeratosis, maceration, fissuring and erosions Note:papulosquamous dermatosis with hyperkeratosis, maceration, fissuring and erosions Eruptions tend to Eruptions tend to be sore rather than be sore rather than itching itching

49 Acute, subacute, or chronic? Swelling? Erythema? Desquamation? Lichenification?

50 Comparison of Classifications of the 3 common types of eczema ACUTEAtopicIgEToxic/IrritantAllergicContact ErythemaXXX PapulesXNAX VesiclesXXX ErosionsXXX CrustsXXX ScalesXNAX Sharp/ confined NAXX Spreading peripherally Flexor surfaces, neck, eye lids, d foot XNA Onset rapid Before age 12 X Usually as adult Onset slow NANAX Concentration L/H NAHL Incidence Other signs Anyone Sensitize d

51 Comparison of Classifications ChronicAtopicIgEToxic/IrritantAllergic/Contact scalingXXX fissuesXXX crustsNAXX papulesNAXX excoriationXNAX lichenificationXNAX Periorbital pigmentation XNANA Infraorbital folds in the eyelids XNANA Foillicular papules X more common in the black pop. NANA

52 Pompholyx (from Greek word meaning blister) Characteristics: Characteristics: Intense itching and burning proceed lesions Intense itching and burning proceed lesions Blisters and vesicles on hands/ feet Blisters and vesicles on hands/ feet Becomes highly exudative Becomes highly exudative Dries up in about 2 wks leaving painful fissuring Dries up in about 2 wks leaving painful fissuring Acute symptom of a chronic problem Acute symptom of a chronic problem Usually no cause but can be due to trichophytin and associated with fungal infection of the feet Usually no cause but can be due to trichophytin and associated with fungal infection of the feet

53 Pomhpolyx cont. Treatment: Treatment: Avoidance of soap Avoidance of soap Emollients Emollients Soaks ( burrows or potassium permanganate) Soaks ( burrows or potassium permanganate) Potent or very potent topical steroids with or with occlusion Potent or very potent topical steroids with or with occlusion Antibiotics for infection Antibiotics for infection Systemic steroids Systemic steroids Coal tar extracts Coal tar extracts Biopsy/testing- usually not necessary Biopsy/testing- usually not necessary

54 Pompholyx Where else should you look? What else might this be call?

55 Nummular Eczema Characteristics: Characteristics: usually -personal or family history of allergy, especially asthma, hay fever, and childhood eczema usually -personal or family history of allergy, especially asthma, hay fever, and childhood eczema Distinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4- 5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic Distinctive Characteristics - Coin-shaped papulovesicular patches that develop in to scaling and crusting lesions; lesions may be as large as 4- 5cm in diameter with distinct margins, initial eruptions on arms and legs; intense itching; tends to be chronic

56 Nummular Eczema cont. Characteristics: Characteristics: Most severe during winter; may be aggravated by systematic administration of iodine or bromine; secondary bacterial infections are common Most severe during winter; may be aggravated by systematic administration of iodine or bromine; secondary bacterial infections are common Treatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection Treatment: skin hydration, topical corticosteroids, intralesional injection, coal tar ointments, UVB treatment, treat secondary infection

57 Nummular Eczema cont. Confused with – contact dermatitis/eczema, atopic eczema, psoriasis, impetigo, tinea corporis Confused with – contact dermatitis/eczema, atopic eczema, psoriasis, impetigo, tinea corporis Biopsy/testing – not usually necessary Biopsy/testing – not usually necessary

58 Note: Coin shaped lesions dorsal surface arms bilateral

59 What else should you think about?

60 Seborrehea Characteristics: Positive family history is common Characteristics: Positive family history is common Seen in all age groups equally Seen in all age groups equally May occur on presternal area and mid upper back May occur on presternal area and mid upper back Stress may increase symptoms Stress may increase symptoms Pityrosporum ovale may be causative factor Pityrosporum ovale may be causative factor Distinctive Characteristics: Distinctive Characteristics: Red greasy scaling rash consists of patches and plaques with indistinct margins and an underlying red glazed look to the skin Red greasy scaling rash consists of patches and plaques with indistinct margins and an underlying red glazed look to the skin Most commonly located in the hairy areas, nasolabial folds, retroauriclar folds Most commonly located in the hairy areas, nasolabial folds, retroauriclar folds Excoriations from scratching are rare Excoriations from scratching are rare

61 Seborrhea cont. Treatment: Scalp – try OTC preps first (antidandruff, tar or ketoconazole shampoo) try OTC preps first (antidandruff, tar or ketoconazole shampoo) Steroid lotions for very short term use Steroid lotions for very short term use 10% Liquor Carbonis Detergens HS and shampoo in AM with Dawn Detergent 10% Liquor Carbonis Detergens HS and shampoo in AM with Dawn Detergent Skin - try OTC’s first try OTC’s first corticosteroids (mild to moderate potency) and/or ketoconazole topically corticosteroids (mild to moderate potency) and/or ketoconazole topically

62 Seborrhea cont. Eye lashes- Warm compresses and gentle debridment Warm compresses and gentle debridment with Q tip with Q tip Sulfacetamide ophthalmic ointment applied topically Sulfacetamide ophthalmic ointment applied topically ** Areas that become exudative may be treated with potassium permanganate or burrow’s soaks Confused with – atopic dermatitis, eczema, psoriasis, discoid lupus, tinea Biopsy/testing – usually none

63 Seborrhea Distribution

64 What else could this be?

65

66

67 Asteatotic Eczema (Xerotic Eczema, “Winter Itch”) Characteristics: Seen mainly in elderly Seen mainly in elderly Worse in the winter Worse in the winter Precipitated by excessive washing Precipitated by excessive washingTreatment: Avoid excessive washing and use of soap Avoid excessive washing and use of soap Emollients Emollients Increase humidity in the environment Increase humidity in the environment Topical steroids for a short periods of time Topical steroids for a short periods of time

68 Localized Neurodermatitis Cont. Treatment: Treatment: Stop the scratching Stop the scratching Occlusive steroid dressings esp. at night Occlusive steroid dressings esp. at night Lubrication Lubrication Doxepin ointment and/or po 10-20mg Doxepin ointment and/or po 10-20mg Hydroxyzine at night Hydroxyzine at night Intralesional steroid injection Intralesional steroid injection Stress management and/or medication Stress management and/or medication Treatment is longterm and may be unsatisfactory Treatment is longterm and may be unsatisfactory Confused with – atopic eczema, psorasis, tinea, seborrhea Confused with – atopic eczema, psorasis, tinea, seborrhea Biopsy / testing – none usually necessary Biopsy / testing – none usually necessary

69 Localized Neurodermatitis (known as Lichen Chronicus Simplex) Characterisitcs: Characterisitcs: Origin often small patch of dermatitis or insect bite starting the itch –scratch- itch cycle Origin often small patch of dermatitis or insect bite starting the itch –scratch- itch cycle Condition unrelated to allergies or family history Condition unrelated to allergies or family history More common in women More common in women Nonseasonal Nonseasonal aggravated by stress aggravated by stress worse at night worse at night may be secondary to atopic eczema, contact dermatitis, lichen planus, psoriasis, or insect bite may be secondary to atopic eczema, contact dermatitis, lichen planus, psoriasis, or insect bite

70 Localized Neurodermatitis (known as Lichen Chronicus Simplex) CONT. Distinctive Characteristics: Lesions lichenified or excoriated Lesions lichenified or excoriated usually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal area usually limited to a single patch at hairline of nape of neck or on wrists, ankles, ears, or anal area Not bilateral Not bilateral Llichenification of dark skin develops a “follicular pattern” Llichenification of dark skin develops a “follicular pattern”

71 Localized Neurodermatitis Distribution (known as Lichen Chronicus Simplex)

72 What should you think about in this man?

73 TREATMENT

74 Stepped Approach to Treatment of Eczema Conservative Therapy Conservative Therapy 1. Education (chronicity, prevention, and trigger id) 2. Use of astringents and emollients/moisturizers 3. OTC products (hydrocortisone, Benadryl, Calamine, etc.) Low to mid potency steroid creams Low to mid potency steroid creams High potency steroid creams High potency steroid creams Immunomodulators - Elidel and Protopic creams Immunomodulators - Elidel and Protopic creams Nontraditional agents Nontraditional agents PO therapy: antiprurutics, steroids, cyclosporine, methotrexate PO therapy: antiprurutics, steroids, cyclosporine, methotrexate Coal Tar Coal Tar PUVA therapy (phototherapy) PUVA therapy (phototherapy)

75 Conservative Therapy

76 Education Chronicity of eczema Chronicity of eczema Association of other conditions: AR, asthma Association of other conditions: AR, asthma Vast number of sensitizing chemicals used currently in our soaps, shampoos, detergents, foods, etc. Vast number of sensitizing chemicals used currently in our soaps, shampoos, detergents, foods, etc. Likelihood of finding a trigger low Likelihood of finding a trigger low Detailed sensitizers/triggers (see Pocket Guide to Medications used in Dermatology by Scheman and Severson) Detailed sensitizers/triggers (see Pocket Guide to Medications used in Dermatology by Scheman and Severson)

77 Patient Resources The Eczema Survival Guide – 30 page guide by the NEASE The Eczema Survival Guide – 30 page guide by the NEASE – the single best general patient medical resource on the internet – sponsored by NIH – the single best general patient medical resource on the internet – sponsored by NIH - National Eczema Society - National Eczema Society – National Eczema Assoc. for Science and Education – National Eczema Assoc. for Science and Education - online dermatology atlas from Johns Hopkins Univ. - online dermatology atlas from Johns Hopkins Univ.

78 Prevention Checklist  Moisturize daily  Wear cotton, avoid wool and tight clothes  Take lukewarm showers, using mild soap or nonsoap cleansers  Pat dry – do not rub  Apply moisturizer within 3 min. to “lock in” moisture  Avoid extremes of heat/humidity and perspiration  Learn triggers and how to avoid them  Keep fingernails short  Remove carpets and pets from the home

79 Soaps and Cleansers Any product that removes skin oils (sebum), dirt, other undesirable substances Any product that removes skin oils (sebum), dirt, other undesirable substances Range from very moisturizing to neutral to very drying Range from very moisturizing to neutral to very drying “If it is dry, wet it; and if it is wet, dry it” – derm mantra “If it is dry, wet it; and if it is wet, dry it” – derm mantra Normal skin pH is ; most soaps are basic and therefore can be irritating Normal skin pH is ; most soaps are basic and therefore can be irritating Rinsing may be an issue if irritating Rinsing may be an issue if irritating Choose the appropriate cleanser to match your patient’s skin type (most eczema patients will need hydration of the skin and neutral or acidic pH) Choose the appropriate cleanser to match your patient’s skin type (most eczema patients will need hydration of the skin and neutral or acidic pH) Again, see Pocket Guide to Medications used in Dermatology for detailed ingredients of skin products Again, see Pocket Guide to Medications used in Dermatology for detailed ingredients of skin products

80 Soap Free Cleansers Cetaphil Cetaphil Aquanil Aquanil Aveeno Daily Mositurizer Aveeno Daily Mositurizer Eucerin Gentle Hydrating Cleanser Eucerin Gentle Hydrating Cleanser Lobana Body Shampoo Lobana Body Shampoo Moisturel Moisturel pHisoderm pHisodermIndications: For use in those eczema patients who may be sensitive to one or more of the various potential sensitizers in soaps and shampoos. To cleanse, reduce irritation (if sensitive to soaps), and reduce dryness (thereby increase absorption of other topicals).

81 Emollients/Moisturizers Aquaphor Aquaphor Balmex Daily Balmex Daily AmLactin AmLactin Cutemol Cutemol DML Forte DML Forte Eucerin Original Eucerin Original Hydrisinol Hydrisinol Lanolor Lanolor Indication: To soften and soothe rough, dry skin and increase absorbability of topical medications Indication: To soften and soothe rough, dry skin and increase absorbability of topical medications Directions: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areas Directions: Apply as necessary or as prescribed; generally after showering/bathing and pat drying; apply liberally to affected areas Neutrogena Norwegian Formula Neutrogena Norwegian Formula Lac-Hydrin Lac-Hydrin Aveeno Aveeno Pen-Kera Pen-Kera Curel Curel Lubriderm Advanced Therapy Lubriderm Advanced Therapy Minerin Minerin

82 Astringents Astringents – reduce secretions (by causing contraction of tissues) and are antibacterial Astringents – reduce secretions (by causing contraction of tissues) and are antibacterial Best used in eczema where vesicular or draining lesions are present Best used in eczema where vesicular or draining lesions are present Acetic Acid 5% (white vinegar) – especially useful in Pseudomonas infections Acetic Acid 5% (white vinegar) – especially useful in Pseudomonas infections Burow’s Solution (Domeboro and others) Burow’s Solution (Domeboro and others) Potassium Permanganate Potassium Permanganate

83 Burow’s Solution (aluminum acetate) Indication: Indication: Used as an astringent wet to dry dressing for relief of inflammatory conditions of the skin such as insect bites, poison ivy, allergy, eczema, and athlete’s foot. Used as an astringent wet to dry dressing for relief of inflammatory conditions of the skin such as insect bites, poison ivy, allergy, eczema, and athlete’s foot. Directions: One tablet or one pack per pint of water = 1:40 solution Actions: Actions: Collagenase enzyme activity may be inhibited by aluminum acetate solution because of the metal ion and low pH. Collagenase enzyme activity may be inhibited by aluminum acetate solution because of the metal ion and low pH.

84 Burow’s Solution As a compress or wet dressing: Saturate a clean, soft, white cloth in the solution. Gently squeeze and apply loosely to affected area. May cover with dry dressing. Saturate the cloth in solution every 15 to 30 minutes and apply to affected area. Repeat as often as necessary As a soak: Soak affected area in solution for 15 to 30 minutes. Discard solution after each use. Repeat 3 times a day

85 Burow’s Solution Precautions: Discontinue use if intolerance, irritation, or extension of inflammatory condition being treated occurs. If symptoms persist >7 days, discontinue use and consult physician Discontinue use if intolerance, irritation, or extension of inflammatory condition being treated occurs. If symptoms persist >7 days, discontinue use and consult physician Do not use plastic or any other impervious material to prevent evaporation Do not use plastic or any other impervious material to prevent evaporation Avoid contact with the eyes Avoid contact with the eyes

86 OTC Therapy

87 OTC Meds Antiinflammatory topicals Antiinflammatory topicals Hydrocortisone creams, 0.5% to 1% Hydrocortisone creams, 0.5% to 1% Antipruritics and others Antipruritics and others 1. Benadryl (diphenhydramine 25-50mg q6h prn) 2. Calamine Lotion (zinc oxide and ferric oxide used as a mild astringent) 3. Caladryl Lotion (both of above) 4. Burow/s solution

88 Prescription Therapy of Eczema

89 Properties of the Ideal Drug (prescription or otc) (Acronym IDEA) (Acronym IDEA) Inexpensive Inexpensive Dosage – once daily or bid or less Dosage – once daily or bid or less Effective Effective Adverse effects absent Adverse effects absent

90 Steroid Creams

91 Basic Rules of Dermal Absorption The larger the surface area the formulation is applied to, the greater the absorption The larger the surface area the formulation is applied to, the greater the absorption Formulations or dressings that increase the hydration of the skin generally improve absorption Formulations or dressings that increase the hydration of the skin generally improve absorption The greater the amount of rubbing in of the formulation, the greater the absorption The greater the amount of rubbing in of the formulation, the greater the absorption The more active inflammation or open vesicles or ulcers present, the greater the absorption The more active inflammation or open vesicles or ulcers present, the greater the absorption The longer the formulation remains in contact with the skin, the greater will be the absorption The longer the formulation remains in contact with the skin, the greater will be the absorption

92 Steroid Classifications

93 Topical Vehicles Creams: Less greasy and most acceptable to patient Less greasy and most acceptable to patient Applies more easily Applies more easily Penetrates skin well Penetrates skin well Works well in intertriginous and hairy areas Works well in intertriginous and hairy areas Can be drying Can be drying Have a cooling effect Have a cooling effect Easy to wash off Easy to wash off Lotions: more water content and less viscous than creams Ointments: Petrolatum based Alleviates dryness by prevention of evaporation Removes scales Enables medication to penetrates skin well Water repellant Remains on the skin Occlusive and protective Soothing and lubricating

94 Prescription Topical Steroids Low and Medium Potency Do consider use in: Allergic/Contact Dermatitis Allergic/Contact Dermatitis Seborrheic Dermatitis Seborrheic Dermatitis Intertrigo of axillary, crural or inframammary regions Intertrigo of axillary, crural or inframammary regions Atopic Eczema Atopic Eczema Neurodermatitis Neurodermatitis Otic eczema Otic eczema Do not use: Large body areas because of expense, difficulty with application, and question of internal absorption

95 Prescription Topical Steroids High Potency and Fluorinated Do consider use: With or without occlusive dressing in palmar or plantar atopic dermatitis With or without occlusive dressing in palmar or plantar atopic dermatitis Localized neurodermatitis Localized neurodermatitis Do not use: Face Intertriginous areas ** prolonged use in any area may cause thinning of the skin, telangiectasia, striae

96 Immunomodulators (Topical immunomodulators-TIM’s)

97 Elidel Elidel (pimecrolimus) 1% cream Indications: Short term and repeated courses for mild to moderate eczema in nonimmunocompromised patients greater that 2 years of age in whom the use of alternative conventional treatment is inadvisable or those with are none responsive to conventional treatment. Short term and repeated courses for mild to moderate eczema in nonimmunocompromised patients greater that 2 years of age in whom the use of alternative conventional treatment is inadvisable or those with are none responsive to conventional treatment. Can be used anywhere on the skin Can be used anywhere on the skin Precautions: Do not use in treatment of infected atopic dermatitis, including eczema herpeticum Patients who develop lymphadenopathy should have a complete evaluation to R/O lymphoma Avoid sun light exposure as sun exposure and use of pimecrolimus shortens time of skin lesion to skin tumor formation in animals Do not use occlusive dressings

98 Elidel (cont’d) Adverse Effects (often resolve after a few days of therapy): Warmth or burning where applied Headache Cold-like symptoms (st, cough, rn) Fever Viral skin infection Dosage: Apply BID Discontinue when symptoms resolved Further evaluation needed if symptoms persist > 6 weeks MOA: Calcineurin inhibitor Cost: 30 grams: $63; 60 grams $117

99 Protopic Protopic (tacrolimus) adults 0.03% & 0.1% ointment Indications: Protopic ointment 0.1% for adults only Protopic ointment 0.03% for children age 2 and older Short term and repeated courses of moderate to severe eczema in whom the use of alternative conventional treatment is inadvisable or those who are not responsive to conventional treatment Can be used anywhere on the skin Precautions: Do not use in treatment of infected atopic dermatitis, including eczema herpeticum Patients who develop lymphadenopathy should have a complete evaluation to R/O lymphoma Avoid sunlight, tanning salons, phototherapy (PUVA), as sunlight shortens time of skin lesion to skin tumor formation in animals Avoid sunlight, tanning salons, phototherapy (PUVA), as sunlight shortens time of skin lesion to skin tumor formation in animals Do not use occlusive dressings

100 Protopic (cont’d) Adverse reactions ( often resolve after few days of application): Skin stinging and burning (dependent on degree of eczema) Increased skin infections Dosage: Apply BID Discontinue 1 week after symptoms resolved Further evaluation needed if symptoms persist > 6 weeks MOA: Calcineurin inhibitor Cost: 30 grams: $62; 60 grams $130

101 Potential problem with both TIM’s (Elidel and Protopic) Feb. 15 th 2005: the Pediatric Advisory Committee of the FDA met and recommended that a “black box warning” be added to both Elidel and Protopic due to “potential cancer risk” Feb. 15 th 2005: the Pediatric Advisory Committee of the FDA met and recommended that a “black box warning” be added to both Elidel and Protopic due to “potential cancer risk” This is due to animal studies where animals swallowed large amounts of both drugs over a long period of time, achieved significant blood levels of the drugs, and developed lymphomas. This is due to animal studies where animals swallowed large amounts of both drugs over a long period of time, achieved significant blood levels of the drugs, and developed lymphomas. March 10, 2005: The FDA issued a Public Health Advisory warning the public about potential carcinogenic safety issues involving both TIM’s. March 10, 2005: The FDA issued a Public Health Advisory warning the public about potential carcinogenic safety issues involving both TIM’s. The American Academy of Dermatology, the Nat’l. Eczema Assn. for Science and Education (NEASE), and the Inflammatory Skin Disease Institute (ISDI) all have issued statements declaring the FDA action premature and all feel that the drugs are safe when used appropriately The American Academy of Dermatology, the Nat’l. Eczema Assn. for Science and Education (NEASE), and the Inflammatory Skin Disease Institute (ISDI) all have issued statements declaring the FDA action premature and all feel that the drugs are safe when used appropriately There are already websites dedicated to class action litigation against both manufacturers There are already websites dedicated to class action litigation against both manufacturers Bottom Line: I would not adivse using in any pediatric patients, or in any patient that can be controlled with less expensive and efficacious therapy. Bottom Line: I would not adivse using in any pediatric patients, or in any patient that can be controlled with less expensive and efficacious therapy.

102 Nontraditional Agents Problem: these are not deemed safe or effective by the FDA Herbal remedies 1. L icorice as topical gel 2. G uava leaves (as tea) 3. C hinese herbal teas 4. S t. John’s wort (as lotion or tea) Probiotics – thought to help relieve inflammation Homeopathic – arsenicum alba and calcara carbonica Hypnosis Acupuncture Gamma linoleic acid oils 1. E vening primrose oil 2. B orage oil

103 PO Prescription Drug Therapy Antipruritics Antipruritics 1. Hydroxyzine 10-25mg q6h prn itching 2. Doxepin 10-25mg q12-24h prn itching (off label) also can be compounded as a cream) Oral Steroids Oral Steroids 1. May give in tapering short courses for selected episodes of acute and/or severe eczema 2. Effective, inexpensive, qd dosing, few side effects in most people with short term use Cyclosporine – reserve for specialty use Cyclosporine – reserve for specialty use Methotrexate – reserve for specialty use Methotrexate – reserve for specialty use

104 Coal Tar Preparations Tegrin cream and lotion Tegrin cream and lotion Medotar ointment Medotar ointment PsoriGel gel PsoriGel gel Polytar and Tegrin soaps Polytar and Tegrin soaps Tegrin, T/Gel, and other shampoos Tegrin, T/Gel, and other shampoos Indication: to relieve and control itching, and flaking skin associated with psoriasis and seborrhea as well as eczema Directions: Depending on product 1-4 times daily

105 Coal Tar Preparations (cont’d) Contraindications: Hypersensitivity HypersensitivityPrecautions: Do not use on broken skin, genital or rectal area except on the advise of your health care provider. Do not use on broken skin, genital or rectal area except on the advise of your health care provider. Photosensitivity x 24hr after application Photosensitivity x 24hr after application May stain light colored hair May stain light colored hairWarning: High concentrations of some chemicals in coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe. High concentrations of some chemicals in coal tar may cause cancer. Concentrations of 0.5% to 5% appear to be safe.

106 PUVA Therapy Indications: Psoriasis, eczema, pruritic rashes of other causes Consists of PO psoralen (photosensitizing agent) followed by UVA phototherapy Must avoid sunlight for 24h after po psoralen Sessions are 3d/wk, may be from sessions, increasing in duration Side effects are redness, burning, occasional nausea Litigation very high in some states

107 Summary of Treatment 1. Conservative Therapy a) Education (chronicity, prevention, and trigger id) b) Use of astringents and emollients/moisturizers c) OTC products (hydrocortisone, Benadryl, Calamine, etc.) 2. Low to mid potency steroid creams 3. High potency steroid creams 4. Immunomodulators - Elidel and Protopic creams 5. Nontraditional agents 6. PO therapy: antiprurutics, steroids, cyclosporine, methotrexate 7. Coal Tar 8. PUVA therapy (phototherapy)

108 Midlevel Provider’s Role in theTreatment of Eczema Identification Identification Treatment Treatment Education Education

109 Identify Acute-Chronic; Allergic,Atopic, Toxic/Irritant

110

111

112

113

114

115

116

117

118 Extra Credit!!!!!

119 The End


Download ppt "Eczema, Two Thousand Rashes and Three Creams A Dermatology Primer for Mid Level Practitioners Mid Level Practitioners."

Similar presentations


Ads by Google