Dermatology.pdf

Dermatology Learning objec2ves Part 1 If pa2ent have skin condi2on, what do you do? - Physical examina2on: o More accurate differen/al diagnosis o Consider privacy in a consulta2on room. o Clearly explain the procedure you want to perform. o Gain the...

Dermatology Learning objec2ves Part 1 If pa2ent have skin condi2on, what do you do? - Physical examina2on: o More accurate differen/al diagnosis o Consider privacy in a consulta2on room. o Clearly explain the procedure you want to perform. o Gain the pa2ent’s consent. o Demonstrate empathy. o Gain experience when recognising skin problems. - History taking: o History of presen/ng complaint à Onset, dura/on, periodicity (it might be allergy) o Site of onset (where?) o Spread/arrangement (discrete (among healthy skin), coalescing (together), grouped (insect bite, scabies) o Distribu/on (symmetrical/asymmetrical, unilateral, localised) à if it’s on one spot. o Feel of lesion (병변) (smooth/rough) o Aggrava/ng or relieving factors o Previous history or family history o Medica/ons à oral or topical, prescribed or OTC o Medical condi/ons à diabetes, SLE o Allergies à to drugs, food, clothing, footwear, jewellery, toiletries, cosme/cs. o Occupa/onal à past and current § Nurses (hand derma//s due to sani/ser), construc/on workers o Sports and hobbies o Animal contacts à cats, dogs, birds, fish, and rodents o Dietary history (sugar, fats, caffeine, alcohol) à it affects the integrity of skin condi/ons. o How pa/ents feel about their skin problem and what they expect for treatment. § It takes /me to get beTer (might not have overnight change) o If the pa/ents travelled recently then may carry viruses à may need to refer. Terminology of descriptors of skin condi2ons Importance of understanding and using common terminology and descrip2ve terms - To take a history thoroughly and examine the affected area. - Assists in differen/a/ng and diagnosing skin condi/ons. - Recording pa/ent notes and interac/ons. - Communica/ng referral to a medical prac//oner. - Repor/ng an adverse drug reac/on. Dermatology terminology (common terms) - Lesion = a single area of altered skin - Rash = widespread erup/on of lesions - Derma22s = eczema = inflamma/on of the skin (not a diagnosis) - Tinea = name of group of diseases causes by fungus - Pruri2s = itchy skin Dermatology terminology (colour) - Erythema/erythematous = redness due to dilated blood vessels that blanch when pressed. - Pigmenta2on = any shade of brown, black, grey or blue resul/ng from the presence of melanin at different depths in the skin - Hyperpigmenta2on = excessive colour in the skin that causes it to be darker than the normal background skin - Hypopigmenta2on = loss of melanin causing the skin to be paler than normal surrounding skin but not completely white Dermatology terminology (texture or morphology of skin lesions and rashes) - Macule = a flat lesion < 1cm in diameter - Patch = a flat lesion > 1cm in diameter - Papule = a raised solid lesion < 1cm in diameter - Nodule = a raised solid lesion > 1cm in diameter - Vesicle = a clear, fluid-filled lesion, < 1 cm in diameter - Bulla = a clear, fluid filled lesion, > 1cm in diameter (like blisters) - Cyst = sac or cavity containing fluid or semi-solid material or air. - Pustule = < 1 cm in diameter, filled with pus (=purulent material composed of inflammatory cells i.e. neutrophils). May be yellow or white, does not always imply infec/on. - Abscess = a pus-filled cyst, usually infected, red and painful. - Scale = increased dead cells stuck together on the skin surface (also called hyperkeratosis) (각질) - Plaque = a solid, raised, plateau – like (flat-topped) lesion greater than 1cm in diameter. - silver scaled plaque Secondary skin changes - These are usually as results of scratching, picking or infec/on: - Lichenifica2on = thickening and accentua/on of skin as a result of the chronic rubbing or scratching. - Crus2ng = arises as a result of plasma exuda/ng through an eroded epidermis. Crust is usually yellow or brown and may ooze (진물이 나다). Epidermal crusts may contain blood, making them look red, purple or black. - Excoria2on = scratching which removes epidermis or localised damage to the skin which causes bleeding or oozing. They are o^en linear (they have line). Dermatology terminology: shape or configura2on of lesions - Annular = in circle or ring - Discoid/nummular = disc or coin shaped circular lesion. - Wheal/weal = superficial skin-coloured or pale skin swelling(raised), usually surrounded by erythema and the skin surface is smooth. Common types of derma22s Derma22s - Nonspecific inflammatory response of the skin - Affects 1 in 5 people during their life/me. - Isolated short episodes (maybe allergy) vs chronic (gene/c) - Causes: o Endogenous e.g. atopic, seborrheic (지루성 피부염), discoid, asteato/c, venous and hand or foot, lichen simplex. o Exogenous (coming from outside) e.g. contact derma//s. o Environmental e.g. irritants, allergens, stress (stress can trigger endogenous type derma//s) Atopic derma22s aka. atopic eczema - Most common inflammatory skin disease worldwide- 230 million people around the world - Life/me prevalence is >15% - Affects people with ‘atopic tendency’ clustering with hay fever, asthma and food allergies. - Atopy is mostly inherited (gene/c) but environmental factors play a role. - Starts in infancy, affec/ng up to 20% of children. - Generalised skin dryness, itch and rash. Treatment - Avoid aggrava/ng factors (soap, shampoo, wool, grass, chlorinated pools) - Moisture with emollients - Topical cor/costeroids as main treatment for all age groups. - Face: hydrocor/sone 1% ointment once daily un/l clear OR [severe] methylprednisolone aceponate 0.1% ointment/FO once daily for 7/7 - Trunk/limb: triamcinolone acetonide 0.02% ointment once daily un/l clear OR [severe] methylprednisolone aceponate 0.1% oint/FO once daily OR [severe] mometasone furoate 0.1% ointment once daily - See TG for specific topical cor/costeroid use for specific parts of the body. - Pa/ents who are unable to tolerate topical cor/costeroids or unsuitable: pimecrolimus 1% cream topically, once or twice daily. - Modified dressings Treat infec2on: - Atopic skin more suscep/ble to bacterial infec/on. - Bleach baths or soak twice weekly: quarter cup of bleach to a standard average-sized bath. - An2bio2c therapy: mupirocin, dicloxacillin, flucloxacillin. Case Study 2: Infan2le seborrheic derma22s aka. Cradle cap What are some specific ques/ons to ask? Why? - How old is the child? o Most common between 3 to 12 weeks. - Is it itchy? o Cradle cap rash does not itch. Atopic derma//s itches. - Where is the rash located? o Usually cradle cap will be on the scalp and/or hairline and/or eyebrows. - Is there a family history of this type of rash? o Pa/ents tend not to have family history in seborrheic derma//s, whereas pa/ents with psoriasis or atopic derma//s do. - What other symptoms are present? o The general health of the child should be unaffected. - What products have been tried? o Need to avoid food-containing products. o E.g. almond oil, coconut oil. à Treatment - Cause unknown, self-limi/ng, clears spontaneously in a few weeks. - Mild cases: o daily applica/on of gentle emollient and shampooing with baby shampoo. Remove scales using a so^ toothbrush or comb. - Moderate cases: o Massage liquid paraffin or baby (mineral) oil into lesions overnight, followed by baby shampoo in the morning. - Persistent cases: o Salicylic acid 2% + LPC 2% + Sulphur 2% in Aqueous Cream, leave on for 6-8 hours then wash out daily or qad. - Lesions not on scalp: o low potency topical cor/costeroids e.g. hydrocor/sone ointment 1% BD. - Refer if non-responsive to OTC treatment. Case 3 – contact derma22s What are some specific ques2ons to ask and why? - What is the rash located? o The distribu/on of rash for contact derma//s closely associated with clothing and jewellery or something they’ve come in contact with. - When did the rash first occur? o A history of when the rash occurs gives a useful indica/on as to the cause. - What do you think triggered/caused the rash? o Pa/ent may be able to isolate the triggering factor. Contact derma22s - Most common occupa/onal skin condi/on (e.g. nurses) - Caused by skin contact with external agents. - Most cases involve hands. - Can have irritant or allergic cause. - Can result from single or repeated exposure regardless of skin type. - 8% of popula/on is allergic to nickel. Irritant contact derma22s vs allergic contact derma22s Treatment - Avoid further direct contact with allergen. - Use rubber gloves with coTon liner or use over coTon gloves. - Remove gloves as o^en as possible because swea/ng may aggravate exis/ng derma//s. - Apply emollients a^er finishing work to improve skin healing. - If occupa/onal e.g. hand derma//s, some/mes a change of occupa/on is needed. - Short course of topical cor2costeroid creams - If severe and acute: oral prednisolone/sone 25 to 50mg once d for 5 to 7 days. Topical treatments General considera2ons with topical treatment of skin condi2ons. - Topical administra2on is oaen preferred – allows direct contact between drug and /ssue, minimising systemic adverse effects. ↑ - When applying more than 1 product to the same area of skin, allow sufficient /me for absorp/on between applica/ons. E.g. topical cor/costeroids and moisturisers. - If the doctor tells you to put two different creams, put one first and wait for liTle bit to be absorbed and then apply the other. Topical drug penetra2on and thereby effec2veness, is influenced by several factors: - Skin damage (e.g. burns, eczema): ↑ permeability. - Scale and crust (e.g. psoriasis): ↓ drug penetra/on. - Lipid structure of skin: facial skin ↑ permeability. - Skin thickness: palms and soles can be resistant to treatment. - Skin areas poten2al for occlusion: skin folds are more permeable. - Skin hydra2on: ↑ systemic drug absorp/on due to factors such as high humidity, occlusion or use of wet dressings - Raised skin temperature: ↑ systemic drug absorp/on. - Children: ↑ SA-weight ra/o, thus absorb higher systemic dose based on weight compared to adults - Preterm neonates: barrier func/on of the stratum corneum is less effec/ve, ↑ permeability. - Elderly: thin/fragile ↑ permeability. Food-based skincare products - Some moisturisers, soaps, nappy rash creams and sunscreens contain foods that are common allergens e.g. goat or cow’s milk, and wheat or nut oils e.g. almond oil, coconut oil. - Assump2on that ‘natural’ is befer. à not true. - Purng food allergens on skin through use of skincare products may sensi2se the person to the food through the skin, leading to the development of the food allergies. - Avoid skincare products that contain food protein especially in people who have eczema who may have inflamed or broken skin, and in babies/children. Addi2ves in products that may cause sensi2sa2on. - A skin sensi2ser refers to a substance that will lead to an allergic response following skin contact. à allergic contact derma22s. - Addi2ves in topical products may cause sensi2sa2on: o Lanolin o Ethylenediamine (stabiliser) o Fragrances o Propylene glycol (humectant) o Preserva/ves e.g. chlorocresol, hydroxybenzoates (paraben) - Creams generally contain more addi/ves than ointments hence more likely to cause sensi/sa/on. Formula2ons - Why creams need preserva/ves? o It is water suspended oil à bacteria lives in water. Ointments don’t have water. Cor/costeroids Safe for breasseeding maybe not around the nipple area. Scheduling of Topical Cor2costeroids How to choose a topical cor2costeroid? 1. Diagnosis 2. Severity 3. Site of applica/on 4. Formula/on 5. Pa/ent preference Potency - Mild: Hydrocor/sone or hydrocor/sone acetate - Moderate: these cor/costeroids are 2-25 /mes as potent as hydrocor/sone - Potent:100-150 /mes as potent as hydrocor/sone - Very potent: 600 /mes as potent as hydrocor/sone à may burn your skin if you put on your face. Site of applica2on. How to apply cor2costeroid - Apply liberally, not sparingly to all areas of inflamed skin (not just to the worst areas). - Reassure pa/ents benefits of topical cor/costeroids outweigh the harms. - Some chronic derma//s requires repeated/intermiTent use. - If topical cor/costeroids are required more than 8 weeks con/nuously, see a specialist. Finger2p unit - Term to explain how much topical cor/costeroid should be applied. - Amount of product that is squeezed out of the tube from the /p of the index finger to the first crease of the index finger. - One average adult finger/p unit is enough to cover the size of 2 flat adult hands with fingers together. How much to apply. - Average-size adults: a single applica/on to cover the whole body requires ~20g ointment or 30g cream. Safety of topical cor2costeroids - Misplaced fear of use à underuse and treatment failure - Topical treatment is safer than systemic (oral) treatments. - LiTle is absorbed through the skin into the body. - Safe for long periods of /me if appropriate formula/on and concentra/on correctly applied. Side effects of topical cor2costeroids Cutaneous drug reac2ons - Defini/on: A drug reac/on that affects the structure or func/on of the skin, its appendages, or mucous membranes - Common adverse skin reac2ons to systemic drugs include: o Morbilliform or maculopapular skin reac/ons o ur/caria and angioedema o fixed drug erup/ons o erythema mul/forme o DRESS (drug reac/on with eosinophilia and systemic symptoms) o Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) - Any drug can cause a predictable or unpredictable reac2on. - Common drugs include: o beta-lactam an/bio/cs o muscle relaxants used in anaesthesia. o sulphonamides and structurally related drugs o contrast media o gela/ne - Pharmacists should always ask for a history of previous reac2ons to drugs prior to handing out the medica2on. Clinical features of severe cutaneous drug reac2ons Examples of cutaneous drug reac/ons When to refer - All cutaneous drug reac/ons should be referred to the prescribing doctor or the GP. - Record reac/on on pa/ent’s profile. - Subsequent exposure is likely to be more severe and increased risk of anaphylaxis. Where to report - All adverse drug reac/ons including CDR should be reported to the TGA. - Report here: Adverse Event Management System (AEMS) When to refer - Severity - Infec/on - Depth - Not responding to treatment - Pain - Heat - Systemic symptoms - Pa/ents at risk e.g. co-morbidi/es, immunocompromised - CDR