Contact Dermatitis (TCS) Student Notes 2024 PDF

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LECOM School of Pharmacy

2024

Vanessa Lesneski

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contact dermatitis topical corticosteroids skin irritations treatment options

Summary

This document is a student lecture note on contact dermatitis. It provides an overview of the presentation and different types of contact dermatitis. Also, it covers a variety of treatments, topical corticosteroids and other treatments.

Full Transcript

Contact Dermatitis 1 hour Vanessa Lesneski, PharmD, BCPS, CPh Objectives  At the completion of this lecture and the readings the student shall:  Explain the presentation of contact dermatitis  Describe treatment goals  Devise an appropriate treatment for a patient based on signs...

Contact Dermatitis 1 hour Vanessa Lesneski, PharmD, BCPS, CPh Objectives  At the completion of this lecture and the readings the student shall:  Explain the presentation of contact dermatitis  Describe treatment goals  Devise an appropriate treatment for a patient based on signs and symptoms  Counsel the patient about treatment options available  List steroids in order of potency Reading  Required  Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 19th Edition Chapter 35 Topical 4 Corticosteroids A mainstay of treating skin irritations 5 Topical Corticosteroids (TCS)  Mainstay of therapy skin irritations, especially if itching is involved  Both ICD and ACD  Urushiol ACD may require a moderate-high potency (prescription) corticosteroid  Strength is impacted by vehicle: Ointment Creams Lotions Solutions Gels Sprays 6 Preferences and Dosage Forms  Creams  Ointments  Easily absorbed into the skin  Not recommended in plant-based ACD or for weeping lesions  Allow vesicle fluid to flow from blisters  Do not apply to open lesions  Do not trap bacteria  Removal is difficult  Cream is an oil-in-water emulsion  May trap bacteria  Drying: weeping lesions  Sprays  Cosmetically appealing  Convenient and easily applied to large  Gels areas of skin  Easy application and rapid absorption of  Does not require touching the dermatitis, active ingredients which could trigger itching  May contain alcohol or similar organic  Aerosol sprays may contain propellants solvents that can cause irritation or burning that cause inflammation and/or alcohol when applied to open lesions that causes drying and irritation 7 General Application of Corticosteroids Apply twice daily, However, 4 times daily may not result in up to 4 times daily better results (↑ cost) Rub product in Preferably when skin is moist (after bathing) thoroughly Hydration of skin will increase absorption Thin skin/sensitive Face, genitals, flexural areas areas Low-potency steroid 8 Key Brand-Generics Cortisone/Cortaid Hydrocortisone Lidex Fluocinonide Westcort Ointment Hydrocortisone valerate Ultravate Halobetasol Kenalog Cream Triamcinolone acetonide 9 Topical Corticosteroid Chart Potency Steroid Class 1: Superpotent; Very high Betamethasone dipropionate 0.05% potency (ointment) Clobetasone propionate 0.05% Diflorasone diacetate 0.05% Halobetasol propionate 0.05% Class 2: Potent; High potency Amcinonide 0.1% (ointment) Betamethasone dipropionate 0.05% (cream/gel) Desoximetasone 0.25% Fluocinonide 0.05% Halcinonide 0.1% 10 Topical Corticosteroid Chart Potency Steroid Class 3: Upper mid-strength; Medium Amcinonide 0.1% (cream) potency Betamethasone valerate 0.1% (ointment) Diflorasone diacetate 0.05% Fluticasone propionate 0.005% (ointment) Mometasone furoate 0.1% (ointment) Triamcinolone acetonide 0.5% (cream, ointment) Class 4: Mid-strength; Medium potency Betamethasone valerate 0.12% (foam) Clocortolone pivalate 0.1% Desoximetasone 0.05% Fluocinolone acetonide 0.025% (ointment) Fluocinolone acetonide 0.2% (cream) Hydrocortisone valerate 0.2% (ointment) Mometasone furoate 0.1% (cream) Triamcinolone acetonide 0.1% (ointment) 11 Topical Corticosteroid Chart Potency Steroid Class 5: Lower mid- Betamethasone dipropionate 0.05% (lotion) strength; Lower- Betamethasone valerate 0.1% (cream, lotion) medium potency Desonide 0.05% (lotion) Fluocinolone acetonide 0.01% (shampoo) Fluocinolone acetonide 0.01%, 0.025%, 0.03% (cream) Flurandrenolide 0.05% Fluticasone propionate 0.05% (cream, lotion) Hydrocortisone butyrate 0.1% Hydrocortisone valerate 0.2% (cream) Prednicarbate 0.1% Triamcinolone acetonide 0.1% (cream, lotion) 12 Topical Corticosteroid Chart Potency Steroid Class 6: Mild; Low Alclometasone dipropionate 0.05% potency Betamethasone valerate 0.05% (cream, ointment) Desonide 0.05% (cream, ointment, gel, foam) Fluocinonide acetonide 0.01% (cream, solution, FS oil) Class 7: Least Hydrocortisone 0.5%, 1%, 2%, 2.5% (cream, potent; Lowest lotion, spray, ointment) potency 13 Hydrocortisone  Available OTC in 0.5% & 1% strengths  Most effective OTC topical therapy for mild–mod CD  Low-potency corticosteroid capable of vasoconstriction  ↓ inflammation & itching  Approved for minor skin irritations  Applied as often as 3–4 times per day  Safe to apply to all parts of the body except the eyes  Systemic absorption is minimal  ↑ absorption if used over large areas, prolonged use, with an occlusive dressing, or when skin integrity is compromised 14 TCS Side Effects All side effects increase based on Drug potency AND Duration of use Cutaneous adverse effects: Skin atrophy Telangiectasia (Spider Veins) Hypopigmentation Steroid acne, increased hair growth, rosacea-like eruptions Easy bruising Striae (linear marks) Hyperproliferation of skin Hypothalamus secretes CRH 15 TCS Side Effects: Systemic Cortisol exerts Chronic High CRH stimulates the negative Dose CS’s release of ACTH feedback on CRH suppresses this from the anterior and ACTH release cycle pituitary  Suppression of the hypothalamic-pituitary-adrenal (HPA) axis  Growth retardation ACTH releases  Eyes: Increased risk of glaucoma; cataracts, mycotic infections cortisol from the adrenal gland  Cushing’s syndrome  Too much cortisol  Fatty hump between shoulders  Rounded face  Striae  Pink or purple stretch marks on skin  Hypertension  Bone loss  Type 2 diabetes ADRs of topical steroids... 16 Striae A) Skin atrophy A&B– B) Hyperproliferation of skin Telangiectasia 17 Topical Corticosteroid Precautions Do not use high potency corticosteroids for more than 3 weeks Risk of tachyphylaxis with extended use Diminishing return with successive use Use caution when applying to groin, armpits, or face Increase risk of side effects: Children, elderly, and patients with liver failure Application to occluded areas Application to large areas Application to broken skin 18 Topical Corticosteroid Contraindications  Acne vulgaris  Viral diseases (herpes simplex, warts)  Ulcers  Skin infections (bacterial, fungal)  Exception: Fungal infections may be treated with a combination with a topical CS 19 Tradeoffs of Low Potency CS‘s Dis- Advantages advantages 20 Tradeoffs of High Potency CS’s Effective! Increased ADRs & Avoid face, folds of skin, & groin Contact Dermatitis  Inflammation of skin in response to irritant or antigenic substance  Characterized by:  redness, itching, burning, stinging, vesicle and pustule formation  Two Types  Irritant contact dermatitis (ICD)  Inflammatory reaction of skin from exposure to irritant (chemicals, typically occupational exposure) https://goo.gl/images/GWuagh  Allergic contact dermatitis (ACD)  Immunologic reaction of skin from exposure to antigen (poison ivy or nickel) ICD vs. ACD Symptom or Characteristic Irritant Contact Dermatitis Allergic Contact Dermatitis Itching Yes, later Yes, early Stinging, burning Early Late or not at all Handbook of Erythema Yes Yes Nonprescription Vesicles, bullae Rarely or no Yes Drugs: An Interactive Papules Rarely or no Yes Approach to Dermal edema Yes Yes Self-Care, 19th Edition, Table 35- Time to reaction (rash) after Dependent on irritant or type of Dependent on antigen 8 exposure irritant Appearance of symptoms Initial or repetitive exposures Delayed for first exposure; in in relation to exposures subsequent exposures, varies based on antigen and sensitivity Causative substances Water, urine, flour, detergents, hand Toxicodendron plants, sanitizers, soap, alkalis, acids, fragrances, nickel, latex, solvents, salts, surfactants, oxidizers benzocaine, neomycin, leather Substance concentration Important Less important at exposure Mechanism of reaction Direct tissue damage Immunologic reaction Common location Hands, wrist, forearms, diaper area Anywhere on body that comes in contact with antigen Presentation No clear margins Clear margins based on contact of offending substance Irritant Contact Dermatitis (ICD)  Who’s at risk?  Occupation-related  People who frequently wash their hands or work in wet conditions  People who work with chemicals/irritants  Diaper dermatitis  Can occur after one exposure, but generally after repeated exposures  Extent depends on  Irritant factors (Amount &/or Concentration)  Patient factors (Existing skin disease, Clothing)  Environmental factors (Temperature, Humidity) Three steps irritation of and disruption of the skin Pathophysiology barrier of Irritant Contact stimulation of epidermal cells Dermatitis release of proinflammatory cytokines that produce inflammation and skin changes Substances Commonly associated with ICD Acids, strong (e.g., hydrochloric, nitric, sulfuric, hydrofluoric) Krinsky, D. L. (2018). Handbook of nonprescription drugs: An interactive approach to self- Alkalis, strong (e.g., sodium, potassium, calcium hydroxides) Detergents, soaps, and hand sanitizers Epoxy resins https://pharmacylibrary.com/doi/full/10.21019/9781582122656.ch35 Ethylene oxide Fiberglass care (19th ed.). Table 35-1. Retrieved August 28, 2018, from Flour Oils (e.g., cutting, lubricating) Oxidants, plasticizers, and activators in athletic shoes Oxidizing agents Reducing agents Solvents Urine and feces Water Wood dust and products Presentation of ICD  Skin inflamed, swollen, and red  Dry or macerated, painful, cracking, itching, stinging, and burning  Symptoms develop gradually  Often Sx are delayed, usually do not occur immediately after exposure  The inflammatory reaction varies, ranging from these initial symptoms to ulcer formation and localized necrosis  Generally, resolves in several days if avoid contact with irritant  If continually exposed to irritant the skin generally remains inflamed  Can develop fissures and scales, hyper- or hypopigmented, crusting, necrosis  Chronic forms of ICD can present with lichenification or leathery thickening of the skin Treatment Goals of ICD Remove offending agent Prevent future exposure Relieve inflammation and irritation Educate patient Treatment of ICD  Non-Pharm  Wash with mild or hypoallergenic soap & lots of water  Pharm  Emollients to restore moisture  Lotions  Colloidal oatmeal baths  **Colloid: a mixture or suspension in which the particles are dispersed throughout another substance and not easily separated  Calamine  Topical corticosteroids (assist with inflammation & itching)  See end of lecture ☺  Avoid:  Topical anesthetics (lidocaine, benzocaine)  Urea, lactic acid, propylene glycol, salicylic acid Allergic Contact Dermatitis (ACD) Substances Associated with ACD Allergen Sources of Allergen Balsam of Peru Cough syrups, flavors Benzocaine The caine-type anesthetics have crossover allergy to other caine-type local anesthetics, approach to self-care (19th ed.). Table 35-2. Retrieved August 28, 2018, from topical medications (for skin, eye, ear), other oral medications Krinsky, D. L. (2018). Handbook of nonprescription drugs: An interactive Chromium salts Potassium dichromate electroplating, cement, leather-tanning agents, detergents, dyes https://pharmacylibrary.com/doi/full/10.21019/9781582122656.ch35 Cobalt chloride Cement, metal plating, pigments in paints Colophony (rosin) Rosin cake for string instrument bows, sport rosin bags, cosmetics, adhesives Epoxy resins Constituents prior to mixing and hardening Formaldehyde Germicides, plastics, clothing, glue, adhesives Fragrances Cosmetics, household products, eugenol, cinnamic acid, geraniol, oak moss absolute Lanolin Lotions, moisturizers, cosmetics, soaps Latex Gloves, syringes, vial closures, elastic waistbands, socks, condoms Nickel sulfate In jewelry, blue jean studs, utensils, pigments, coins, tools, many metal alloys encountered daily Neomycin sulfate Medications, antibiotic ointments, other aminoglycosides Plants Toxicodendron species (poison ivy, oak, sumac), primrose (Primula obconica), others Rubber (carba mix) Added ingredients, accelerators, activators, other processing chemicals Thimerosal Preservative in many medications, injectables, cosmetics Allergic Contact Dermatitis 31  Main cause is poison ivy/oak/sumac  Plants belonging to the Toxicodendron genus  80% of U.S. is allergic to urushiol  Oleoresin that causes the allergy  Plant must be damaged to be released  Remains on inanimate objects for years!  Can be transferred from one area to another or from pets  Carried in smoke particles if plant is burned  If allergic to one plant in class, generally allergic to all  Allergy seen as early as 3 years old  Sensitivity increases until age 10, then declines in elderly  Elderly have a reduced response, but symptoms last longer 32 Identifying Toxicodendron Species  5 different species present in the United States  Have 3 leaves from a central stem with the middle leaf sticking out the most  “Leaves of 3; let it be!” Pathophysiology of ACD  Inflammatory reaction due to allergen exposure  Sensitized T cells are activated, T cells migrate to site of contact, & release inflammatory mediators  Dermatitis does not generally appear on first contact  During the initial exposure (induction phase) the antigen sensitizes the immune system  Subsequent contact with the antigen induces a cell-mediated, type IV delayed hypersensitivity reaction (within 24 hours to 21 days)  This reaction results in ACD  If previously sensitized rash & symptoms appear up to 48 hours after exposure Presentation of ACD Red skin with vesicles of bullae https://goo.gl/images/fyKqvr Itching Localized to the areas of contact ACD is generally spread over multiple areas Goals of treatment Remove and Relieve itching avoid further Treat the and prevent contact with the inflammation excessive offending agent scratching Prevent/treat Prevent oozing, crusting, secondary skin and scaling of infections vesicles Exclusions for Self-Care Children under the age of 2 36 Dermatitis for >2 weeks Involvement of >20% of BSA Extreme itching, irritation, or severe vesicle and bulla formation Swelling of the body or extremities Swollen eyes or eyelids swollen shut Discomfort in genitalia from itching, redness, swelling, or irritation Involvement &/or itching of mucous membranes of mouth, eyes, nose, or anus Low tolerance for pain, itching, or symptom discomfort Impairment of daily activities Failure of self-care after 7 days Signs of infection Non-Pharm Treatments  Prevention  Avoid Toxicodendron plants  Wear preventive clothing and wash clothing  Clean surfaces with soap and water or rubbing alcohol  Use barrier products  Identify and remove plants  Proper protective clothing, cover nose and mouth Non-Pharm Treatments  If exposed  Wash area of exposure ASAP with soap and lots of water Special washes that target urushiol Zanfel Tecnu Cold or tepid showers for itching Trim fingernails to reduce risk of bacterial infections 39 Tecnu Outdoor Skin Cleanser  Mix of mineral spirits, water, soap, and a surface-active agent  Used as soon as possible, but up to 8 hours after exposure is okay  Cleanse for 2 minutes with product and wash off with cool water https://goo.gl/images/cmcTak 40 Zanfel  Binds to urushiol and can be used at anytime after exposure  Claims to stop itching within 30 seconds  Directions  Wet area  Use at least 1.5 inches of product and rub into a paste  Rub onto affected area until itch stops – no more than 3 minutes  Rinse area thoroughly  May repeat when itch returns https://goo.gl/images/36BTH2 Pharm Treatments  Itching  Do not use topical anesthetics, antihistamines, or antibiotics  Sensitizers  Night-time relief  PO 1st gen antihistamine (not >65 yoa)  Colloidal oatmeal baths  Weeping  Astringents  Inflammation  Topical corticosteroids 42 Astringents  Decrease edema, exudation, and inflammation  Reduce cell permeability  Also cool through evaporation  Vasoconstrict  Cleanse  Dry skin and decrease inflammation  Used as a soak or wet compress  Products available: Aluminum acetate (Burow’s solution), zinc oxide, zinc acetate, sodium bicarbonate, calamine, witch hazel  Use is generally for 5-7 days while the skin is moist and oozing 43 Follow-Up  If still itching and weeping severely after 5-7 days of therapy, see PCP  If reappears a few days after symptoms clear  May take up to 3 weeks for total clearing of dermatitis References  Lexi-comp. Accessed 2018-09-04. “Topical Corticosteroids.” http://online.lexi.com.lecomlrc.lecom.edu/lco/action/doc/retrieve/docid/ patch_f/3674386  Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 19th Edition Chapters 33 & 35  Nicolaides NC, Pavlaki AN, Maria Alexandra MA, et al. Glucocorticoid Therapy and Adrenal Suppression. [Updated 2018 Oct 19]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279156/

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