NUR 7575 - Acute Dermatologic Conditions in Primary Care

Acute Dermatologic Conditions

• Impetigo is a contagious superficial skin infection prominent on exposed areas of the face and extremities
• Highest risk is common in children in sports, daycare, warm or humid environments
• Presents as small superficial vesicles that are usually multiple and described as "honey crusted"
• Topical mupirocin (Bactroban) TID, wash with antibacterial soap or chlorhesidine (Hibiclens) are useful treatments.
• Fifth disease is a common viral infection (Parvovirus B 19) characterized by an eruptive rash, sore throat, mild fever, runny nose, nausea, headache, and itching
• The rash is not contagious once it develops, and one may return to school
• Phase 1: slapped cheek syndrome with circumoral pallor occurs (2-4 days)
• Phase 2: erythematous maculopapular rash on extremities and trunk, fading into a centrally clear, lacy pattern (1-6 weeks)
• Phase 3: persistent, variable rash worse during heat, stress, sunlight (1-3 weeks)
• Pregnant women can pass virus to fetus, urgent referral to specialist
• Supportive treatment is key
• Hand-foot-and-mouth disease is a highly contagious viral illness (Group A coxsackievirus)
• Symptoms include lesions on the buccal mucosa, palate, palms of the hands, soles of the feet, and buttocks
• While common in children, it can affect adults
• It is typically self-limiting, with resolution in 7-10 days
• Patients exhibit a prodrome of fever, URI symptoms, and sore throat. Painful mouth lesions often precede skin lesions, including rash on hands and feet
• Symptomatic care is key: avoid aspirin in children with febrile illness due to the risk of Reye's syndrome-swelling in liver and brain
• Erysipelas is a distinct form of cellulitis notable for acute, well-demarcated, superficial bacterial skin infection, common on face, scalp, and extremities
• Most common pathogen is Streptococcus pyogenes
• Patients may have fever, headache, vomiting, chills, and arthralgia
• Treat with penicillin, Bactrim, or cefazolin
• A chronic form exists
• MRSA (Methicillin-resistant Staphylococcus aureus) usually presents with erythema, warmth, tenderness, swelling, indurated center, and possible abscess
• Experience tenderness, heat, pain, oozing, swelling, and redness
• Key Risk factors: "spider bite", HX of MRSA, athlete
• A wound culture is needed if purulent lesion + systemic signs of illness
• Trimethoprim-sulfamethoxazole (Bactrim), Doxycycline, Clindamycin are useful treatments
• Cat Scratch Disease involves subacute tender lymphadenitis that develops after contact with a cat, scratch being most common
• A red macule develops at contact site and evolves into fluid- filled vesicles and crusts, unilateral lymphadenopathy within
• It lasts 1-2 weeks and may last 2 to 8 weeks
• It is self-limiting and resolves in 2 to 6 months
• Treat with analgesics, antibiotic in immunocompromised
• Pityriasis Rosea, is an idiopathic, self-limited skin eruption characterized by widespread papulosquamous lesions most common on face, trunk, and distal extremities
• Hallmark sign is salmon-colored oval patches or plaque known as herald patch, 2-10cm
• Generalized rash develops 1-2 weeks later, where oval lesions appear like a "Christmas tree rash".
• Patients require treatment for mild pruritis with oral or topical antihistamine, topical steroids, or oral steroid if itching is severe
• Resolution occurs in 6-12 weeks
• Herpangina is a viral infection that causes fever and multiple vesicles, followed by painful mouth ulcerations involving the soft palate, uvula, and tonsils
• It is usually transmitted by fecal-oral route but can be in respiratory droplet
• Abrupt onset of fever, sore throat, yellowish/grey/white vesicles surrounded by red halo
• Treat symptoms: analgesics topical anesthetics
• Resolves in 7-10 days but viral shedding lasts 4 to 6 weeks
• Oral Candidiasis is a fungal infection of the membranes of the mouth that may involve the throat, esophagus, and trachea
• Appears as white oral plaques on erythematous base
• Risks include being immunocompromised, use of inhaled corticosteroids, antibiotics, dentures, infant < 6 months
• Treat with oral antifungal agents (Nystatin oral suspension, fluconazole (Diflucan)
• Resolves within 2 weeks
• Diaper Dermatitis, presents as an acute inflammation of skin in the region of the perineum, buttocks, lower abdomen, and inner thighs (contact, atopic, candida, seborrheic)
• Common in pediatric patients and adults with urinary or fecal incontinence due to prolonged contact with wet/soiled diaper
• Treat through open air exposure, skin barrier ointment (zinc oxide), topical antifungal, or topical low-potency corticosteroid (combo products on market)
• Tinea Versicolor is a fungal infection appearing as well-marginated lesions of varying color (white, red, or brown)
• Impacts the shoulders, chest, back, and axilla
• Risks include a hot, humid climate
• Tinea Pedis is a fungal infection of feet that presents with itching, odor, burning sensation, maceration in toe webs, scaling or blistering on soles of feet
• Risks include athletes and being immunocompromised.
• Onychomycosis is a fungal infection of the fingernails and toenails
• Risks include being immunocompromised, having tinea pedis, PVD, older adult, or using a communal swimming pool
• Tinea Capitis is fungal infection of the scalp
• Presents as round, patchy scales on scalp with/or without alopecia
• Treat with Griseofulvin orally for 4 to 6 weeks, take with high-fat
• Intertrigo is superficial fungal skin infection located on intertigenous areas with increased warmth, humidity, or friction
• Classic case is obese patient complaining of bright-red and shiny
• Pediculosis is an infestation of the body, head, or pubic area by lice, with a 1-month incubation
• Head and body lice are common in children
• Risks include prolonged proximity to infected people or sharing

Acne

• It is important that acne be treated based on skin type.
• Dry skin: creams and lotions
• Oily skin: gels and solutions
• Hairy areas: lotions and foams
• Treatment selection based on the acne severity, present and past treatments
• Systemic treatment is indicated for moderate to severe inflammatory acne resistant topical therapy
• Systemic therapy should be used in conjunction with retinoid or benzoyl peroxide

Acne Topicals

• Topical antimicrobials are an intervention
  • Benzoyl peroxide
  • Pregnancy Category C
  • Common side effects include may bleach hair or clothing, dryness, redness, peeling
  • Dapsone
    • Pregnancy Category C
    • May cause temporary yellow or orange skin and hair
  • Clindamycin or Erythromycin
    • Pregnancy Category B
    • Monotherapy not recommended due to antibiotic resistance
    • Use with benzoyl peroxide or retinoid
• Topical retinoids are a treatment via Tretinoin or Adapalene
  • Pregnancy Category C
  • Each binds to a different set of retinoic acid with slight differences in efficacy, tolerability, and activity
  • Will cause skin irritation and treatments should start 2-4 times per week and advance to nightly use as tolerated.
  • Exercise caution in people with fish allergies
  • Common Side Effects include dry skin, peeling, scaling, burning sensation, erythema, pruritus, sunburn, change in pigmentation
• Combination Topicals include:
  • Benzoyl peroxide + retinoid
  • Benzoyl peroxide + antibiotic
  • Retinoid + antibiotic

Systemic Acne Treatment

• Tetracyclines should NEVER be given to children under 8 years of age or pregnant due to risk of permanent bone/teeth discoloration
• Avoid as monotherapy, and use with topical benzoyl peroxide to prevent antibiotic resistance or topical retinoid to improve results
• Treatment may take 2 to 4 months
• Macrolide options include Erythromycin, which is a 2nd line option if patient cannot tolerate tetracycline
• Macrolides can improve results Use with topical retinoid but not with topical antibiotic
• Resistance up due to overuse

Combined Oral Contraceptives

• FDA approval for acne specifies that combined oral contraceptives are approved for treatment of acne in women who also desire contraception
• Not to be used as 1st line therapy
• Same screening guidelines as with patients seeking contraception

Shingles

• Antiviral treatments include:
  • Valacyclovir
  • Acyclovir (more frequent dosing, less expensive)
• Pain control:
  • NSAID
  • Capsaicin Cream
• Avoid use of topical antibiotics
• May take up to 3 weeks for rash to resolve
• Pain may last for 3 months or more

Dermatitis and Corticosteroids

• Dermatitis and Corticosteroids
• Do not use oral steroids if patient has diabetes or infection suspected
• Topical corticosteroids most common therapy
• Use corticosteroid treatments for the shortest duration possible to prevent cutaneous atrophy
• Choose optimal vehicle according to case (ointment, cream, lotion, solution, gel, foam)
• Type of steroid treatment can be (Cortisone, Triamcinolone, Betamethasone)
• Use only mild potency for face, neck, groin, or axilla
• Avoid use of fluorinated topical steroids on the face
• Prescribe appropriate amount (whole body coverage takes 30 gms, estimate amount to prescribe by calculating whole body % needing medication using Rule of nines)

Infestations

• Treatments for Scabies or lice include:
  • Permethrin
  • Ivermectin
  • Malathion
• Bedbug or flea bites:
  • Corticosteroid topicals
• May have to repeat treatment in one week to kill eggs
• Treat all household members and sexual partners
• Malathion is highly flammable and a poison

Common Derm Terms

• A Lesion is any single area of altered skin that may be solitary or multiple.
• A Rash is a is widespread eruption of lesions
• Dermatosis is another name for skin disease.
• Nummular Lesion are round (coin-shaped) lesions, also known as discoid
• Linear Lesion has a linear shape to a lesion often occurs for some external reason such as scratching and also striate
• A Gyrate rash appears to be whirling in a circle.
• Annular lesions grouped are in a circle
• Erythroderma is where the skin condition affects the whole or nearly the whole body and is red all over
• Telangiectasia is the name given to prominent cutaneous blood vessels.
• Purpura is bleeding into the skin and may be as petechiae (small red, purple or brown spots) or ecchymoses (bruises). Purpura does not blanch with pressure (diascopy).
• A Macule is an area of color change less than 1.5 cm diameter where the surface is smooth.
• A Patch refers to a large area of colour change, with smooth surface.
• Papules are small palpable lesions, usually defined as less than 0.5 cm diameter, although some sources say 1.5 cm they are raised above the skin surface and may be solitary or multiple.
• Vesicles are small fluid-filled blisters less than 0.5cm diameter and they may be single or multiple
• A Pustule is a purulent vesicle that contains neutrophils, and may be white, or yellow. Not all pustules are infected.
• Bulla is a large fluid-filled blister and may be a single compartment or multiloculated.
• Abscess is a localised collection of pus
• A Weal is an oedematous papule or plaque caused by swelling in the dermis and wealing often indicates urticaria.
• Distribution refers to how the skin lesions are scattered or spread out. Skin lesions may be isolated (solitary or single) or multiple. The localisation of multiple lesions in certain regions helps diagnosis, as skin diseases tend to have characteristic distributions. What is the extent of the eruption and its pattern?
• Acral affects distal portions of limbs (hand, foot) and head (ears, nose).
• Blaschko lines follow a roughly linear, segmental pattern described by Blaschko and thought to be indicative of somatic mosaicism.
• Dermatomal Corresponding with nerve root distribution.
• An Extensor involves extensor surfaces of limbs, while the other contrast with flexor surfaces
• Flexural and involves skin flexures (body folds); are also known as intertriginous.
• Follicular and individual lesions arise from hair follicles while These may be grouped into confluent plaques.
• Generalised are of universal distribution: may be mild or severe, scattered or diffuse
• Herpetiform form Grouped umbilicated vesicles, as arise in Herpes simplex and Herpes zoster infections.
• The Koebnerised phenomenon refers to the tendency of several skin conditions to affect areas subjected to injury, arising in a wound or scar.

NUR 7575 - Acute Dermatologic Conditions in Primary Care