Dermatology Self-Care: Atopic Dermatitis & Skin Overview

Dermatology Self-Care Topics: Overview

• The lecture covers atopic dermatitis, dry skin, scaly dermatoses, and diaper dermatitis.

Skin Overview and Drug Absorption

• The skin and its appendages such as hair and nails protect the body from external harmful agents, which include pathogenic organisms, chemicals, and radiations.
• Skin plays a key role in hydroregulation, mainly controlling transepidermal water loss (TWEL).
• The 3 layers of the skin are the epidermis (outermost layer), dermis (middle layer), and hypodermis (subcutaneous layer).
• The hypodermis is the lower layer, which provides a cushion and nourishment to the above layers.
• The stratum corneum, the outermost layer of the epidermis, is the rate-limiting barrier for drug absorption.
• The major drug mechanism for absorption is passive diffusion through the stratum corneum.

Atopic Dermatitis (AD)

• Dermatitis is considered a non-specific term referring to various dermatological disorders, and is defined as erythema and inflammation.
• Atopic dermatitis (AD) is a common, pervasive inflammatory condition affecting the epidermis and dermis.
• Patients with AD typically present with episodic flares that alternate with periods of remission.
• AD is most commonly observed in children younger than 5 years of age.
• Clinically, AD presents as scaly, erythematous, edematous, papular, and crusty skin.
• Approximately 80% of AD cases also present with asthma and allergic rhinitis, which is commonly referred to as the Atopic Triad.
• Pathophysiology of AD involves increased levels of cytokines, specifically interleukins IL-4 and IL-13 as well as chemokines.
• Genetic predisposition, such as the presence of certain mutations (Filaggrin gene), can lead to a deficient skin barrier, evident within a family history of AD.
• There are new biomarkers including CD30, IL-12,-16,-31.

Diagnosing Atopic Dermatitis

• Diagnosing AD is determined through clinical evaluation and diagnosis.
• There is no established laboratory test for AD, however some patients may have elevated IgE levels, but this is not consistent in all individuals.
• The severity of disease can be validated through one of three severity assessments: SCORAD (Scoring Atopic Dermatitis), EASI (Eczema Area and Severity Index), and POEM (Patient-Oriented Eczema Measure).
• Essential features of the diagnostic criteria include pruritus and eczema (chronic or relapsing history).
• Important features include early age at onset, xerosis (dry skin), and atopy (IgE reactivity).

Clinical Presentation of AD

• Itch that rashes is the hallmark presentation in early childhood.
• In children, AD involves areas of the face, neck, forehead, and extremities, erythema and scaling of cheeks.
• AD in adults most commonly involves the antecubital and popliteal fossae, neck, forehead, eyes, and hands.
• Three clinical forms of AD are acute, subacute, and chronic.
• Acute AD is characterized by intense pruritic papules, which are small, firm, and red elevated bumps alongside exudates, which are secreted substances.
• Subacute AD presents as erythematous, excoriated papules and large, elevated, flat lesions, which are scale.
• Chronic AD is characterized by lichenification, which is the thickening and accentuated skin markings.

Secondary Infections

• Secondary infections are difficult to prevent.
• More than 90% of patients with AD exhibit colonization of Staphylococcus aureus.
• Infected lesions will show crusted yellowish eczematous lesions.
• Viral infections, such as herpes simplex or molluscum contagiosum, are common.
• Medical attention should be sought if signs of bacterial or viral infections are noticed, like a 1 cm diameter pus containing vesicles, yellow crusting, etc.

AD Treatment

• AD cannot be cured but symptoms can be managed to stop the itch-scratch cycle.
• The goals are to maintain skin hydration, barrier function, minimize trigger factors, and prevent secondary infections.
• General treatment approach includes avoiding triggers, hydrate skin, and using topical agents if needed.

Common AD Triggers

• Food allergens (e.g., egg, milk, peanut, soy, wheat, nuts) trigger AD
• Aeroallergens (e.g., dust mites, cat dander, mold, grass, pollen) trigger AD
• Psychological stress triggers AD
• Airborne irritants (tobacco smoke, air pollution, traffic exhaust) trigger AD
• Cosmetics, fragrances, and astringents trigger AD
• Irritating soaps, detergents, and scrubs trigger AD
• Excessive hand washing or bathing/showering triggers AD
• Dyes and preservatives. trigger AD
• Tight-fitting or irritating clothes (wool or synthetics) trigger AD

Nonpharmacological Therapy

• Retain moisture through bathing hygiene and moisturizing.
• Limit bath/shower time to 3-5 minutes and first 5 minutes hydrates the skin where longer than 5 minutes dehydrates.
• Use lukewarm water, not hot water.
• Bathe daily or every other day (QOD).
• Avoid soaps, as they contain long chain fatty acids that can dry the skin.
• Non-soap cleansers such as Cetaphil Restoraderm, are preferred, if needed.
• After bathing, pat the skin dry and avoid rubbing.
• Use moisturizer to skin immediately after bathing.
• Keep fingernails short, smooth and clean.
• Wear cotton gloves/socks on hands to bed if itching at night.
• Maintain high room humidity in the bedroom at night by a humidifier.
• Avoid extreme temperatures exposure (heat or cold).
• Wet Wraps entail applying emollient or steroid to lesions, and wrapping in a wet and dry layer overnight.

AD: Pharmacological Agents

• Several pharmacological agents that are approved or in process of approval and implementation as topical and prescription oral medications for self-care treatment options, but only immunomodulators agents are available.
• Believed to suppress cytokines related to inflammation and itching, topical corticosteroids work.
• .5-1% low potency topical corticosteroids are available over-the-counter
• Topical corticosteroids are safe to use in patients > 2 years of age can be used on any part of the skin except on the eyes and eyelids.
• Side effects are skin atrophy are common with high potency corticosteroids.
• Apply sparingly twice daily to affected lesions during flares, before any moisturizer for weeping lesions and avoid topical steroids for use more than 7 days.

AD: Anti-pruritics:

• Topical anti-histamine is not recommended.
• Oral anti-histamine may help with sleep for insomnia related to excessive itching, example antihistamines include Diphenhydramine, Cetirizine and Chlorpheniramine.
• Oral anti-histamines are not recommended for routine treatment of pruritus in AD.
• Oral anti-Histamine side effects may include sedation, anti-cholinergic side effect in first generation anti-histamines like dry mouth, urinary retention.

When To Refer For AD

• Exclusion of self-care includes
  • Moderate to severe condition with intense pruritus
  • Involvement of a large area of the body
  • < 1 year of age
  • Skin appears to be infected
  • Involvement of face or intertriginous areas
  • If symptoms worsen or didn't improve after 2-3 days of treatment, REFER to PCP

Patient Education

• Avoid factors that trigger allergic skin reactions such as clothing or environmental irritants and proven food allergens and temperature extremes and changes in humidity.
• Take short showers or baths using lukewarm (tepid) water and a nonsoap cleanser and substitute sponge baths (with tepid water).
• Pat skin dry after bath or shower, to help prevent injury to the affected area, keep your fingernails short, smooth, and clean, wear cotton gloves or socks on your hands to lessen scratching.
• Gently wash the affected areas with a nonsoap cleanser before applying topical moisturizers and moisturizer within 3 minutes after washing while skin is still damp.
• Apply a thin layer of nonprescription hydrocortisone 1–2 times daily to dry lesions but do not use this medication longer than 7 days.
• Noticeable improvement can be observed within 24–48 hours, although completely eliminating the rash and itch is possible by consulting your primary care provider.

Dry Skin (Xerosis)

• Dry skin (xerosis) results from a decreased water-holding capacity of the skin.
• Dry skin affects more than 50% of adults over 65 years and is commonly seen in cooler environments that are commonly seen in the winter season.
• Its pathophysiology is the barrier dysfunction due to decreased lipid components (ceramides, fatty acids, cholesterol).
• Systemic disorders as hypothyroidism, cholestasis, renal failure, dehydration may be associated.
• Clinical Presentation: Roughness, scaling, cracking, erythema, pruritus.
• Treatment Goals: Improve skin hydration, restore skin's barrier function, and education the patient about prevention and treatment.

Dry Skin Treatment

• Not more than 3°F for tepid water to bath in for brief periods (3-5 minutes).
• Dry Skin treatment include tub add oil bath 2-3 times per week and use sponge baths for other days.
• Within 3 minutes get out of the tub, pat the body barely dry and generously apply body moisturizer to trap the moisture.
• Additional steps include using corticosteroid ointments rather than creams if short-term use and maintaining high room humidity are indicated.

Dry Skin Non-pharmacological Treatment

• Bath oils provide lubrication by vegetable or mineral Oils that is commonly combined with colloidal oatmeal can be added to bath water or as a wet compress, however can create a slippery safety hazard.
• Use a glycerin soap to cleanse the skin by avoiding typical soaps to remove natural lipids, increase skin pH.

AD: Moisturizing

• Petrolatum, Mineral Oil or Lanolin, Glycerin, urea, hyaluronic acid and Ceramides brand names used to moisture dry skin.

Dry Skin Nonpharmacological Treatment

• Many moisturizers are mixtures of oils and water, and more severe cases of dry skin may require a product containing a humectant such as glycerin, urea, lactic acid to enhance hydration.
• Types of moisturizers like ointment, cream, lotion or gel each have different characteristic uses from thick skin to cooling effect.

Dry Skin: Patient Education

• Reduce water loss and moisture loss to avoid excessive bathing, take brief full and sponge baths, avoid alcohol because they can contribute to dehydration.
• Maintain room humidity and apply Moisturizers generously 3–4 times daily.
• Apply moisturizers immediately after bathing 1-2 times daily and use a product that contains ceramides or pseudoceramides alongside a moisturizer.
• Consult a primary care provider to seek medical attention if a skin dryness worsens.

Scaly Dermatoses

• Scaly dermatoses encompass conditions affecting the skin's upper layer (epidermis), which includes dandruff, seborrheic dermatitis, and psoriasis.
• All manifest as varying degrees of scaling of skin of skin, inflammation, and erythema.

Dandruff

• Dandruff is an accelerated epidermal cell turnover and abnormal keratinization of accelerated epidermal cell turnover and abnormal keratinization, involving Malassezia yeast .
• The yeast produces fatty acids and cytokines that cause the irritation.
• The treatment 1st approach is weekly routine shampooing and avoid harsh surfactant shampoos and 2nd approach is nonprescription medicated shampoo should be used with soak timing.

Dandruff - Medicated Shampoo

• Cytostatic Pyrithione shampoo’s and Selenium sulfide apply massaging and leave on hair for 3-5 minutes.
• Antifungal ketoconazole 1% agent to wet hair, lather for 8 weeks.
• Side effects can cause photoallergenicity hypersensitivity reaction and discontinue if it causes irritation
• Additional treatments are keratolytic shampoos with salicylic acid requires longer treatment and Coal tar can stain lite hair and cause folliculitis.

Seborrheic Dermatitis

• The pathophysiology occurs because it is involved in seborrheic dermatitis, increased activity, enhanced sebaceous gland increases yellow scale and stress.
• It can increase the risk of developing seborrheic and chronic neurologic and treatment goals are reduce inflammation, visible erythema and itch.
• Therapy focuses on loosening scales, yeast control with Anti-fungal or Mineral/ Olive oil and Shampoos or gentle baby shampoo for treatment with erythema in infants.

Psoriasis

• Chronic inflammation in which 50% clear spontaneously is unpredictable, can cause distress and cell turnover.
• Equal in women and men in descending order has higher incidence in obese >lower in African American >Asian
• Treatment controls symptoms 3 times and is possible with treat cases of few lessens otherwise with a quarter referral is needed.

Psoriasis

• Scale removal assists to increase penetration and Moisturizing product is need to be generously rubbed up to 4 times.
• Use hydrocortisone 1% ointment for lesions.

Scaly Dermatoses- Patient Education

• Nonpharmacologic approaches include avoiding physical and chemical injuries, trauma, UV light-exposure, tobacco, and alcohol.
• Use medicated shampoo for at least 5 minutes and for four weeks, apply a a thin layer of hydrocortisone.
• Symptoms improvement could be observed within 7-14 days.

Scaly Dermatoses-Self Treatment

Self treatment exclusion for Psoriasis:

• < 2 age with worsened symptoms

• 5 % body area BSA or face involvement

• More then few lesion or if lesion is greater then a quarter, referral is required.

Diaper Dermatitis

• Diaper dermatitis and prickly heat are acute dermatologic conditions and is not generally serious, with discomfort and itching.
• Can manifest at day 7 for any infants with in continents and has many factors like alkaline pH, friction and microbes.

Diaper Rash

• Diaper rash is erythematic a the top with lesions and patches.
• The goals are to relieve symptoms, rid the patient and discourage infection.

Diaper Rash Treatment

• To treat diaper rash, follow the mnemonic ABCDE: air, barrier, cleansing, diaper and education.

Pharmacological Agents for Diaper Rash

• Topical antibiotics and antifungals are NOT appropriate for self-care treatment without referral; the most often used barrier is zinc oxide.
• Common ingredients found in skin protectants are Allantoin, Calamine, Cocoa butter, Cod liver oil, Colloidal oatmeal, Glycerin & Petrolatum

Selected Nonprescription Products Diaper Dermatitis

• Zinc and petrolatum for the Diaper.

Diaper Dermatitis: Patient Education

• Use the mnemonic ABCDE, do not use rubber or plastic pants, use plain water (instead of wipes/alcohol), and if possible, allow the infant to go without a diaper.
• Benzocaine or hydrocortisone is contraindicated in diaper dermatitis and to discard discarded products and avoid clogging skin pores.

Diaper Dermatitis and Heat

• If diaper rash has lesions present, there's lack to therapy or complicated infection.

Prickly Heat(Heat Rash)

• Comes from locked or clogged sweat glands, and on chest and upper axillae during humid or sweaty weather.
• The goal of treatments goals are is 1-Eliminate occlusion 2-Protect skin irritation and sweat 3- Healing the body.