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Define macules
flat lesions of any shape or size that differ from surrounding skin because of their color (e.g. birthmark or freckle)
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Define papules
small, solid, elevated lesions that are less than 1 cm in diameter (not fluid-filled)
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Define plaque
a mesa-like elevation that occupies a relatively large surface area in comparison with its height above the skin
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Define nodule
- palpable, solid, round or ellipsoidal lesions with varying depth of involvement into the skin
- (papules that extend under the skin)
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Define wheal
rounded or flat-topped papules or plaques that are characteristically evanescent, disappearing within hours and usually itch (usually from allergic rxn)
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Define vesicle and bullae
blisters; vesicles are < 0.5 cm in diameter and bullae are > 0.5 cm in diameter
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Characteristics of xerosis
- AKA: dry skin, winter itch
- decreased water content in stratum corneum
- s/s: roughness, scaling, loss of flexibility, fissures, cracks, inflammation and/or pruritis
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What is the most common dermatologic problem in children?
atopic dermatitis
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S/S and other names for atopic dermatitis
- aka: eczema, "the itch that rashes"
- s/s:
- Chronic, relapsing (relapsing and remitting)
- intensely pruritic
- xerosis
- edema
- erythema
- oozing vesicles with or without excoriations
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what is the atopic triad?
- asthma
- allergic rhinitis
- atopic dermatitis
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What areas are most common for atopic dermatitis at which ages?
- 0-2 years: face and scalp
- 2 years - puberty: wrists, ankles, neck
- Adult: upper arms, back, wrists
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How is atopic dermatitis diagnosed?
- If pt has itchy skin + 3 of the following:
- onset < 2 years
- hx of skin crease involvement
- hx of generally dry skin
- personal or 1st degree relative hx of other atopic disease
- visible flexural dermatitis
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Non pharmacologic treatment of atopic dermatitis
- decrease exposure to triggers
- drink water
- humidifier/vaporizer
- diet (questionable)
- bathing (soak & seal - apply moisturizer within 3 min)
- keep nails short
- wear loose fitting cotton clothing
- avoid all triggers
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What is the teaspoon rule?
- tells the amount of moisturizer to use
- one teaspoon per arm, chest, abdomen, upper back, lower back, each thigh, each shin
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Compare emollients vs. moisturizers
- Emollients smooth the skin
- Moisturizers hydrate the skin
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What do humectants and keratolytics do?
- humectants attract water
- keratolytics soften scales
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Exclusion for self treatment of atopic dermatitis
- 1. severe condition with intense pruritis and crusting (severe flare)
- 2. involvement of large area of the body
- 3. less than 2 years of age
- 4. infected lesions
- 5. treatment for 7 days with no resolution
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Treatment algorithm for atopic dermatitis
- Weeping lesion:
- cool tap water compress, astringents
- topical antibiotics if infx present (honey-colored crusting)
- Dry lesion:
- moisturizers and emollients throughout the day plus:
- colloidal oatmeal
- topical glucocorticoids (up to 7 days)
- oral antihistamines
- topical calcineurin inhibitors
- cyclosporine A, azathioprine, interferon gamma, mycophenolate mofetil, phototherapy
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Should topical antihistamines and anesthetics be used in atopic dermatitis and contact dermatitis? Why or why not?
No because they are skin sensitizers
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What are the 2 types of contact dermatitis and common causes?
- Irritant contact dermatitis - caused by exposure to irritant (e.g. strong acids/bases, detergents, fiberglass, leather, solvents, etc.)
- Allergic contact dermatitis - caused by exposure to allergen (poison ivy/oak/sumac, metal)
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What is the chemical that causes the allergic reaction to poison ivy?
urushiol
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s/s of contact dermatitis
- inflamed, swollen, red skin
- vesicles and bullae
- intense itching - may lead to skin breakdown and open lesions
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Nonpharmacologic treatment of contact dermatitis
- remove irritant/allergen
- wash self and objects with soap and water
- men should shave
- trim nails
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Treatment algorithm for contact dermatitis
- Weeping lesions:
- tap water compress
- astringents
- Dry lesions:
- colloidal oatmeal
- shake lotion, sodium bicarb compress/paste
- topical corticosteroid
- counterirritants, oral antihistamines
- oral steroids (1mg/kg/day tapered over 2-3 weeks)
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can topical corticosteroids/glucocorticoids be applied to broken skin? can counterirritants?
- steroids can
- counterirritants cannot
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Exclusions for self-treatment of contact dermatitis
- Less than 2 years old
- greater than 2 weeks duration
- greater than 25% of body surface area
- extreme itching, irritation, or severe vesicle and bullae formation
- swelling of the body and/or extremities
- swollen eyes
- involvement of mucous membranes
- impairment of daily activities (e.g. it's on the bottoms of feet, hands, etc.)
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Signs/symptoms of first degree and second degree sunburns
- First Degree: superficial burn, mild erythema, tenderness, pain, edema, pruritis, macular
- Second Degree: visicles, bullae, fever, shills, weakness, shock
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What is the max SPF there is?
50+
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How is the UVA protection with sunscreen rated?
4 star rating (low, medium, high, highest)
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How much sunscreen is needed per body part for proper protection?
1/2 tsp
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Define "water resistant" and "very water resistant" in terms of sunscreens
- water resistant retains SPF for at least 40 minutes when sweating or swimming
- very water resistant retains SPF for at least 80 minutes when sweating or swimming
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What is the difference between organic and inorganic sunscreens?
- Organic - the active ingredient absorbs at least 85% of UV rays
- Inorganic - the active ingredient reflects or scatters all light (physical barrier)
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What are the major categories of sunscreen ingredients?
- PABA and derivatives
- Anthranilates
- Benzophenones
- Cinnamates
- Dibenzoylmethane Derivatives
- Salicylates
- Misc.
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What agents fall under which categories of sunscreens?
- PABA and derivatives - Aminobenzoic Acid (PABA), Padimate O
- Anthranilates - Menthyl anthranilate
- Benzophenones - Dioxybenzone, Oxybenzone, Sulisobenzone
- Cinnamates - Cinoxate, Octyl methoxycinnamate, Octocrylene
- Dibenzoylmethane Derivatives - Avobenzone
- Salicylates - Octyl salicylate, homosalate, Trolamin salicylate
- Misc. - Terephthalyidene dicamphor sulphonic acid, Phenyl benzimidazole, Titanium dioxide, Zinc dioxide
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Which sunscreens are sensitizers?
- PABA (aminobenzoic acid)
- Benzophenones (dioxybenzone, oxybenzone, sulisobenzone)
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Which sunscreens are weak and do not adhere well?
the salicylates (octyl salicylate, homosalate, trolamin salicylate)
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Which sunscreen provides protection for the entire UVA range, and what is its problem?
Avobenzone - it is not photostable
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Nonpharmacologic treatment of sunburn
- cool with tap water for 10-30 min
- do not pull loose skin
- stay hydrated!
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Treatment algorithm for sunburn
- Dry Burn:
- skin protectant, emollient/moisturizer
- Weeping Burn (2nd degree):
- cool tap water compress/soak
- topical antibiotics if infx present
- Painful Burn:
- local anesthetics (3-4x/day)
- oral NSAIDs
- topical hydrocortisone
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Should astringents or counterirritants be used to treat sunburns?
no
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Exclusions for self-treatment of sunburn
- more than 2% of body surface area (for regular burns, not sunburn)
- treatment for 7 days with no resolution
- generalized edema
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Which type of insects bite pattern is a linear formation?
bed bugs
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Characteristics of Lyme disease
- Spirochete found in deer ticks
- Initial rash is papule that enlarges to a bulls-eye rash that disappears in 3-4 weeks
- Infection spreads and pt experiences flulike sx and muscle aches
- Years later - neurologic and cardiac sx
- Finally, arthritis and red discoloration on hands, wrists, feet, or ankles
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Are insect repellants effective for stinging or biting insects?
biting, not stinging
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How does DEET work, and how should it be used?
- It discourages insect approach
- Apply max of q6hours (nmt qd in kids)
- spray clothing
- it decreases the efficacy of SPF
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Alternative insect repellants
- citronella
- lemon eucalyptus
- soybean oil
- tea tree oil
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Nonpharmacologic treatment for insect bites/stings
- Remove stinger
- ice packs
- trim fingernails
- RICE therapy (rest, ice, compression, elevation)
- Bedbugs: Vacuum daily, petroleum jelly on bed legs
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Treatment algorithm for insect bites/stings
- topical antihistamines, topical hydrocortisone
- counterirritants, shake lotion
- local anesthetics, oral NSAIDS
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Exclusions for self treatment of insect bite/stings
- hypersensitivity
- Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing
- Hx of significant allergic response to any sting
- Allergic response away from sting
- Less than 2 y.o.
- tick bite
- spider bite requiring medical attention (brown recluse, black widow)
- s/s of infx
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Treatment for scabies
- Permethrin Rx
- Cover entire body, wash in 8-12 h, retreat if necessary
- Lots of counseling necessary
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Nonpharmacologic treatment of pediculosis
- Nit comb over a 10 day period (as monotx, or following pediculocides)
- Petrolatum for eyebrows or eyelashes
- Vacuuming furniture/rugs
- Wash bedding and clothes in washer and dry in dryer
- Seal unwashable items in plastic bag for 2 weeks
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Pharmacologic treatment for pediculosis
- Pediculicides - neurotoxins that cause paralysis - pyrethrin, permethrin (ovicidal)
- Benzyl alcohol lotion - suffocates the lice (not ovicidal)
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Counseling re: pediculicides
- May cause scalp irritation
- ONLY for actual infestation (don't use as prevention)
- Must use nit comb
- Only repeat if necessary
- Do not use on eyebrows or eyelashes
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Exclusions for self-treatment of pediculosis
- Hypersensitivity to chrysanthemums or ragweed
- Evidence of secondary infx
- Less than 2 y.o.
- Infestation of eyebrows or eyelashes (sign of sexual abuse)
- Pregnancy or lactation
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Important points regarding product selection for dermatologic conditions
- If it's wet, dry it
- If it's dry, wet it
- Water in oil is more effective (e.g. ointment)
- Oil in water is more esthetic (e.g. lotion) and may evaporate, causing a drying effect
- Do not use ointments, shake lotions, or counterirritants on weeping lesions
- Topical antihistamines and anesthetics are known sensitizers
- Aerosol products may be drying or irritating and are not protective
- Avoid camphor in children
- Ointments > Creams > Lotions
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Atopic dermatitis is a _______ disease state that requires both _________ and ____________ treatment to maintain the integrity of the stratum corneum. How do we prevent flares?
- chronic
- Preventive and active
- use emollients and moisturizers to prevent flares
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When treating urushiol induced contact dermatitis what is the #1 thing to do?
- Eliminate the urushiol
- Must use nonpharmacologic measures to prevent recontamination
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What type of product is best for preventing sunburn?
A product with good UVA and UVB protection. Be sure to apply it correctly.
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What is the difference in treatment of insect bites vs. insect stings?
no difference
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What is extremely important to consider with the use of pediculocides?
- Only treat with them when necessary
- Do not use for prevention
- Patients must take non-pharm measures to control the infestation
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Why should topical corticosteroids not be applied to eye area or eyelids?
They can thin the skin (epidermal atrophy)
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When should sunscreen be applied and how often?
15-30 minutes prior to sun exposure and reapplied q 2-3 hours
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