Xerosis and Dermatitis 2 Flashcards Preview

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Flashcards in Xerosis and Dermatitis 2 Deck (32)
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1
Q

Questions to Assess Patient

A

Symptoms: Itch? Pain? Burning? Lack of sleep? Any systemic symptoms?
Characteristics: Can you describe the dermatitis? Oozing? Erythema? Fissures? Hypo or hyper pigmentation? Scaling? Thickening of skin? Signs and symptoms of infection?
History: How long? Does it come and go? Have you experienced this before? History of atopy? History of edema in lower limbs?
Onset: When did it start? What were you doing? Anything change in your life at that point?
Location: Where is it?
Aggravating Factors: What make it worse? Probe with specific examples.
Remitting Factors: What makes it better? Probe with specific examples.
Explanatory Model: How does this symptom or condition affect you?

2
Q

Red Flags

A
  • Concomitant skin infection
  • Large body surface area is involved, open wounds that are oozing or blistering
  • Systemic symptoms present (fever, malaise, pain)
  • Patient is psychologically distressed and requires an assessment
  • Patient needs a prescription drug product?
  • Assess you competency as a prescriber
  • Patient is experiencing side effects from prescribed treatment
  • Treatment failure (after you assess adherence)
  • Ambiguity on diagnosis
  • Pharmacists need to be astute in considering differential diagnoses of skin conditions
3
Q

Goal of Therapy (4)

A

Incorporate patient’s goals as well as clinically
suggested goals
Suggestion of goals:
- Restore barrier function
- Provide symptomatic relief while decreasing skin lesions
- Implement proactive measures focusing on preventing or decreasing the number of flares or exacerbations
- Increase symptom free periods and empower patient/caregiver with strategies to manage skin condition
- Decrease impact on quality of life and psychosocial distress
due to condition

4
Q

General Principles of a Care Plan for Xerosis and Dermatitis (3)

A

Combination of multiple non-pharmacological interventions (patient education) and +/- pharmacological agents (moisturizers +/- nonprescription drugs +/- prescription
drugs)
General principles for xerosis and dermatitis
1. Avoid aggravating/contributing factors and eliminate cause as applicable
2. Implement lifestyle measures
3. Add pharmacological treatment, first with moisturizers for uncomplicated cases to help restore barrier function and then add prescription products as needed

5
Q

First step details for care plan - 1. Address Contributing Factors

A

Can these factors be addressed:
• Hypothyroidism,
initiate thyroid hormone supplement
• Keep skin covered to avoid weather elements (wind, extreme heat)
• Can irritating or drying skin products be discontinued?

6
Q

First step details for care plan - 2. Self-care Measures

A

• Avoid excessive bathing or long baths or showers; use tepid water
• Increase humidity indoors
• Cool mist humidifiers preferred
• Humidity should be between 40% and 50%
in winter (30% in summer)
• Avoid wool clothing that may be irritating to the skin
• Cotton clothing next to the skin is less irritating
• Avoid swimming in chlorinated pools (Practical?)
• Avoid products that contain ingredients that may
sensitize the skin
• Maintain good nutrition and adequate fluid intake
from food and water
• Stress management

7
Q

First step details for care plan - 3. Moisturizer & Principles

A
  • Choose noncomedogenic, nonirritant and hypoallergenic moisturizers
  • Helps to restore the barrier capability of the epidermis and decrease TEWL
  • Patients will have to use on an ongoing basis
  • Apply the moisturizer after bathing while skin is damp
  • Apply several times a day (3–4 times daily)
  • If using a bath product to moisturize, add bath products at the end of a bath or after a bath
  • Replace standard soap with a substitute such as a synthetic detergent cleansers
8
Q

Moisturizer: Occlusive agents - MOA? Examples? Notes?

A

Form a layer on the skin that inhibits moisture evaporation. Used in conjunction with hydration.
Examples: mineral oil, dimethicone, petrolatum
Additional notes:
- These agent are not appealing on the face
- In very hot and humid climates, can be overly greasy and occlusive

9
Q

Moisturizer: Humectants - MOA? Examples? Notes?

A

Hygroscopic, attract water to the skin
Examples: Alpha-hydroxy acid (AHA) (glycolic acid,
lactic acid), glycerin, propylene glycol, urea
Additional notes:
- Formulations may sting if used on open wounds. People with sensitive skin may not tolerate.
- Use with an occlusive agent. Lactic acid (>12%) and urea (>10%) are keratolytic and their use is reserved for
treatment of more severe skin conditions with thick scales

10
Q

Moisturizer: Emollients - MOA? Examples? Notes?

A

Fill in the spaces between stratum corneum, sealing moisture in the skin. Lubricate stratum corneum and slow evaporation. Most are oil in water or water in oil emulsions (the more oil, the less evaporation due to increased occlusion).
Examples: colloidal oatmeal, glycol, glyceryl stearate, shea butter and soy sterols
Additional notes:
- Choose an emollient for its drying or lubricating properties as suitable for the stage of dermatitis.

11
Q

Misc Products: Bath products- MOA? Examples? Notes?

A

Provide a layer of oil on the skin that prevents moisture
evaporation
Examples: colloidal oatmeal, liquid paraffin
Additional notes:
- Best applied at the end of the bath or shower or
immediately after using a wet compress. Safety hazard if added to bath water (increased chance of slipping).
Colloidal oatmeal relieves itching and enhances the barrier function of the skin. Avoid fragranced bath salts and bubble baths.

12
Q

Misc Products: Barrier Repair Products - MOA? Examples? Notes?

A

Normalize skin barrier by replacing lipids; decreasing
transepidermal water loss (TEWL); decreasing response to triggers for inflammation.
Example: Ceramides/cholesterol/free fatty acids
combinations, filaggrin, silicone and/or zinc related
compounds
Additional notes:
- Need to apply liberally

13
Q

Topical Corticosteroids - what is it? formulation types?

A

Reduce inflammation and pruritus, useful for acute flare and chronic presentation
Various potencies:
- Potency depends on: chemical structure of the steroid molecule, concentration, and formulation/vehicle
- Low potency recommended for thinner skin, higher potency for thicker skin
Various formulations (gel, lotion, cream, solution, ointment, spray, foams)
- In general ointments are considered more potent, more occlusive, contain less preservatives. Creams are suggested in excessive heat or humid environments. Sprays, foams and solutions are good for hair bearing
areas.
- The formulation type can cause potency differences of two or three classes between preparations with the same corticosteroid molecule!

14
Q

Topical Corticosteroids - site absorption

A
Relative absorption:
Forearm -1
Sole-0.14
Back-1.7
Scalp-3.5
Forehead-6.0
Cheek-13.0
Scrotum-42.0
15
Q

Topical Corticosteroids - Counselling tips

A

Apply a thin layer to affected area as prescribed (usually qd or bid).
- Suggest finger tip unit
Use in conjunction with a moisturizer = greater efficacy of steroid.
If patient using continually (daily), suggest 3 weeks “on” and 1 week “off” approach to mitigate tachyphylaxsis to TCS and minimize side effects.
To maintain remission, patient may use TCS twice weekly with moisturizer being used daily.

16
Q

Topical Corticosteroids Side Effects

A
  • Topical side-effects
  • Skin thinning (usually after prolonged use and incorrect potency)
  • Telangiectasia and erythema
  • Striae
  • Poor wound healing
  • Hypopigmentation
  • Flare-up of underlying, untreated infection (i.e. fungal, viral or bacterial)
  • Development of acne
  • Perioral dermatitis if steroid used excessively on the face
  • Systemic side-effects (rare)
  • Hypothalamic-pituitary-adrenal axis suppression
17
Q

How do you mitigate side effects from TCS?

A
  1. Steroid breaks
  2. Taper down for maintenance therapy
  3. Monitor potency and duration of therapy
18
Q

Atopic Dermatitis - Specific Care Plan

A
  1. Mild disease: Moisturizers and patient education on
    lifestyle measures
  2. Moderate to severe disease: Moisturizers + TCS/TCI
    or crisaborole + patient education on lifestyle
    measures
  3. Severe disease: All of the above +/- dupilumab,
    phototherapy, other immunosupressants (out of the
    scope of PMCO 1)
19
Q

Atopic Dermatitis- Specific Care Plan Extra Notes

A

• There is insufficient evidence to recommend the use of probiotics for treatment of established AD
• Maternal use of probiotics during pregnancy or maternal/infant use of probiotics during breastfeeding “may be helpful” in prevention of AD
• Lack of consensus as to what strain and dose should be suggested. Select good quality product and use as
directed on bottle.
• Evidence for Traditional Chinese Medicine and the use of acupuncture is conflicting, evidence is of poor quality
• Evening primrose oil (gamma-linolenic acid) does NOT provide essential fatty acids help restore barrier

20
Q

Irritant Contact Dermatitis- Specific Care Plan

A
  1. Obtain a good social history that helps identify
    potential occupational triggers.
  2. Treatment is to avoid the irritants, protect the skin
    (gloves, barrier creams, dimethicone-containing creams)
    and occasional use of topical steroids
21
Q

ABCDE of Diaper Dermatitis - A’s (4)

A

Air:
- Allow diaper area to air dry between changes. Do not
use a hair dryer or heat lamps!
Absorptives:
- Use diapers that absorb moisture and wick it away
from skin.
- Generally, do not recommend powder/talc (risk of
inhalation) or corn-starch (medium for candida growth).
- If the parent wants to use powder/talc, have the parent apply it to a cotton puff or their hands first.
Anti-fungals:
- Diaper dermatitis is often colonized with yeast
- Drugs of choice include miconazole (unscheduledtopical use), clotrimazole (unscheduled-topical use) and nystatin (schedule 3, slightly less efficacious than the previous two antifungals).
- Apply anti-fungal first then barrier cream
Anti-inflammatories:
- May use 0.5-1% hydrocortisone
- Higher potency corticosteroids may cause side effects

22
Q

ABCDE of Diaper Dermatitis - B (1)

A

Barriers:

  • Barrier creams helpful in minimizing irritant contact with skin
  • Petrolatum is widely favored by parents, however, I still prefer and recommend a zinc oxide paste
  • Caution with additives causing sensitization (e.g. aloe, lanolin, fragrances)
23
Q

ABCDE of Diaper Dermatitis - C (2)

A

Cleansing:
- Warm water on a clean cloth or cotton pads preferred choice (mild soaps, soapless cleansers may be used)
- Wipes containing fragrances, lanolin, alcohol or methylisothiazolinone may cause irritation. Use water based wipes.
- Pat diaper area dry before applying barrier creams and diaper
Compressing:
- Oozing or crusting lesions can be compressed with wet dressings (tap water, saline)

24
Q

ABCDE of Diaper Dermatitis - D (1)

A

Diapers:

  • Change diapers frequently, especially if soiled
  • Do not cover diaper with plastic “underpants”
  • Personal preferences in regards to cloth vs. disposable (choose breathable disposable diapers)
25
Q

ABCDE of Diaper Dermatitis - E (1)

A

Education:

- Patients and care givers must understand preventative and treatment measures

26
Q

Allergic Contact Dermatitis - Specific Care Plan

A
  1. Treatment of ACD hinges on detection of the allergen
    (through “patch testing”)
  2. Avoidance of allergen and use of topical
    corticosteroids for acute flares.
27
Q

Stasis Dermatitis - Specific Care Plan

A
1. Relieve the swelling
• Compression stockings
• Elevation of limbs
2. Use moderate to potent TCS
3. Patients with stasis dermatitis are particularly prone to developing allergic contact dermatitis (use inert
products!)
28
Q

Management of Itch - Histamine details

A

Histamine does not play a prominent role in itch development in dermatitis, however, we will resort to the use of first generation antihistamines or second
generation antihistamines
- First generation (i.e. hydroxyzine) helps by making the patient drowsy so they do not
itch anymore. Side effects are an issue!
- Second generation antihistamines are better tolerated (i.e. bilastine, rupatadine, cetirizine)
- Goal is to manage condition, therefore, itch should resolve
- Do not suggest topical antihistamines (diphenhydramine is a sensitizer!)

29
Q

Management of Itch - Concomitant Infection

A

Topical corticosteroids may be combined with topical anti-infectives: E.g. Osanex®, Fucidin®, or Bactroban® cream/ointment applied bid
In moderate-severe disease (atopic dermatitis only), bleach baths may be recommended for those with frequent bacterial infections
-Add ¼ - ½ cup of common 5% household bleach to a bathtub full of water (40 gallons). Soak your torso or just the affected part of your skin for about 10 minutes.
Limit diluted bleach baths to no more than twice a week.

30
Q

Dermatitis - Monitoring Plan

A

Monitoring parameters include (see Table 3 in Xerosis Chapter and Table 9 in Dermatitis Chapter):
- Scaly, flaky skin
- Itching
- Improvement in skin lesions
- Are of body surface involved
- Psychological state
Have patient keep a diary
Topics to consider: Amount of emollient used, use of prescription drugs, degree of itch, change in lifestyle (what helped and what made it worse), quality of sleep, mood, what products (drug and nondrug) work and do not work
Give treatment regimen a 7-10 day trial to see if there is improvement (assess adherence)
- Treatment failure of dermatological therapies is often due to lack of patient adherence.
Patient needs to be part of designing a treatment regimen as this will increase the chance of adherence.
Monitor for side effects of pharmacological treatment as applicable

31
Q

Dermatitis - Follow-up

A

Have patient follow-up in a few days (7-10 days)
- If condition worsens, is unresponsive or new symptoms develop = refer patient to physician for assessment
and change in therapy
- Always monitor for the development of “Red Flags”
Pharmacists that have knowledge in disease
management may step-up therapy or add additional
pharmacological agents

32
Q

what are the different types of moisturizers? (5)

A
occlusive agents
humectants 
emollients
bath products
barrier repair products