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Eczematous skin disorders PowerPoint Presentation

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Description : Check out this medical presentation on Skin Condition, which is titled "Eczematous skin disorders", to know about the functions of skin, skin lesions, eczema and other dermatides, and outpatient management of eczema.

Tags : Skin Condition, Eczematous, skin disorders, functions of skin, skin lesions, eczema, dermatides

Published on : Jul 05, 2021 | Views : 2013 | Downloads : 5

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Slide 1-

Eczematous skin disorders Dr. Ravneet Sekhon, PGY3 Pediatrics Telehealth Rounds Thanks to Dr. Ramien for her feedback and support in preparation of this presentation!
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Objectives Describe the functions of skin Description of skin lesions Eczema and other dermatides Outpatient management of eczema
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Functions of the skin Protection Protective barrier Radiation shield from UV light Mechanical, chemical, thermal insults Relatively impermeable to water Microbes Sensation: receptors Thermoregulation Insulates from heat loss Heat loss through evaporation of sweat Metabolic function Subcutaneous fat stores energy Vitamin D synthesized in epidermis in presence of UV light
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Normal skin anatomy
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Careful and detailed history should be gathered regarding onset, inciting factors, evolution of skin lesions, pruritus, medications/immunizations, family hx
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Describing skin lesions Describe: Size Shape Color Texture Configuration (relation to each other) Distribution (where on the body)
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Review of common skin lesions Macule; flat and <1 cm Patch; flat and >1 cm Papule; raised and <1 cm Plaque; raised and >1 cm Nodule; raised with more deep component, <1 cm Tumor is > 1 cm Vesicle: small bubble, fluid filled, <0.5 cm Bulla: >0.5 cm Pustule: pus containing bubble; can be related to hair follicles
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Great resource with modules - https://www.aad.org/education/basic-derm-curriculum/suggested-order-of-modules/morphology (American Academy of Derm)
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Eczematous disorders Erythema, edema, pruritus, weeping Chronic: thick, dry, scaly lesions with lichenification and changed pigmentation Includes: Eczema or atopic dermatitis Seborrheic dermatitis Allergic and irritant contact dermatitis Nummular eczema Acute dyshidrotic eczema
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Diagnosis?
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Nickel dermatitis A type of allergic contact dermatitis Due to prolonged or repetitive exposure Improves after removal of stimulus but recurs quickly on re-exposure Temporary treatment with topical or oral corticosteroids - what steroid, how much, and for how long? Education of parents about cause
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Contact dermatitis Irritant contact dermatitis: Dry skin dermatitis: from repetitive wet-to-dry like lip licking, thumb sucking, etc. Juvenile plantar dermatosis: red scaly lesions on weight bearing aspects of foot due to wearing occlusive footwear Diaper dermatitis: irritant, infection (Candida) Allergic contact dermatitis: poison ivy, poison oak, nickel
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Diagnosis?
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Diagnosis?
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Diagnosis?
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Diagnosis?
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Pityriasis alba Mainly in kids 3-16 yo, M=F Hypopigmented, ill defined, round or oval patches Can be mildly erythematous and have fine scales Location: face, neck, upper trunk, prox arms Frequently misdiagnosed: vitiligo, tinea versicolor, tinea corporis Treatment: emollient, low potency topical steroid or calicineurin inhibitor
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Diagnosis?
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Seborrheic dermatitis Also called cradle cap in infants Greasy scaling of scalp, axillae, groin folds; in adults face, eyebrows, upper trunk Salmon pink patches that can flake or peel Not itchy Infants<3 mo Associated with proliferation of various Malassezia species Treatment: keratolytics, topical antifungals, mild corticosteroids.
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Diagnosis?
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Atopic dermatitis 10-30% of kids worldwide Most common relapsing-remitting skin condition Occurs with other atopic dz like: asthma, allergic rhinitis, food allergy
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Etiology Genetic mutations in filaggrin in up to 50% Defective skin barrier Reduced skin innate immune responses Exaggerated T cell response to environmental allergens and microbes Chronic skin inflammation
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Infants Toddlers School kids Adults
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Many have Staph aureus colonization at time of flare and may have altered cellular immunity Higher risk of developing generalized eczema herpeticum
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Differential diagnosis
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Management Prevention Bathing: lukewarm baths or showers; mild skin cleanser (unscented); pat skin dry Moisturize: traps water in the skin and improves barrier function. Can be applied throughout the day PRN. Aveeno, Glaxal base, Cliniderm, Vaseline, etc. Clothing: avoid wool, rough clothes; prefer cotton. Loose, light clothes in warm weather. Bedroom: Vacuum bedroom carpet daily Use special mattress and pillow covers under cotton liner or mattress cover Change furnace filters q3-4 months Wash sheets and mattress cover weekly Humidifier
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Replace scratching with moisturizing, etc. Wet wrap overnight, after moisturizing or medicated creams are applied (for flares) WET WRAP VIDEO: https://www.youtube.com/watch?v=CMX_AEu_Oro
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Treatment Topical corticosteroids: what can you apply and where? Treat the itch!: antihistamines orally, also has sedative effect for sleep Antibiotics for superinfections
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What kind of topical preparation to use? The various preparations: Ointment: Less likely to produce burning/stinging (no preservatives) More effect with the same active ingredient and concentration bc of their occlusive effect Need only to apply a thin layer to affected areas until they are smooth to touch Cream: more cosmetically acceptable Lotion: good for hair-bearing areas Oil based: easier to spread (esp useful in large areas of skin are involved) and are not too strong (useful for mild-mod eczema); Ex. Dermasmooth Foam
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Topical corticosteroids Mild: hydrocortisone 1% ointment to red raised itchy areas on face or folds BID PRN Mild-mod: Desonide 0.05% ointment on face or body BID PRN Moderate: Betaderm 0.1% ointment to body BID PRN Severe: Clobetasol propionate 0.05% to palms and soles BID PRN; not on body usually
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Risks of steroid use: Cutaneous atrophy Striae Telangiectasias Systemic absorption -> adrenal suppression Around mouth: peri-orificial dermatitis Around eyes: intraocular HTN, cataracts
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Common questions Which steroid can be used for daily prevention use (proactive use)? None How to manage acute flares? Treat red, raised, rough areas with topical steroids for up to 1-2 weeks at a time; if not improving by then seek MD How much steroid is safe to prescribe in the clinic? Limit prescribing to low potency steroids for face/neck/skin folds and moderate to trunk/extremities If red, raised rough areas not resolved in 1-2 weeks, then reassess and consider other diagnoses. If still convinced pt has eczema, step up to next level potency steroids and reassess. If eczema, should resolve. If a particular steroid in a particular class doesn’t improve symptoms, is there any evidence that an alternate steroid from the same class might work better? Not usually unless the patient has been using the same one for a LONG time and has tachyphylaxis How frequently can higher potency steroids be used for flares? (ex. in one year) 1-2x/month but if they are flaring this often, they might need better baseline or maintenance treatment to avoid flares ie. 1-2x/week application of BMV/calcineurin inhibitor to recurrent areas. When to consult Dermatology? Lack of response to routine treatment Features not compatible with eczema Needing to use treatment cream every day continuously Needing better eczema education/reinforcement of general measures If would like a one-time consultation to confirm diagnosis, make it clear on consultation that you would like to continue following the patient after consultation performed
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Topical calcineurin inhibitors Topical immuno-suppressants Inhibit T cell activation 2 forms: Tacrolimus (Protopic) 0.03% and 0.1% ointment; only 0.03% approved for 2-15 yo kids Pimecrolimus 1% cream Second line therapy for recurrent areas Adverse effect profile is different from steroids More costly Adverse effects: Stinging/burning, pruritus – tend to be brief (few days) Rare cases of skin malignancy and lymphoma reported; continuous long term use not recommended and limit application to affected areas only Prolonged systemic exposure associated with inc risk of infections Unknown if interferes with skin response to UV damage; minimize/avoid sun Health Canada recommends if sx do not improve in 6 weeks of BID treatment, then discontinue and reassess diagnosis
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Treat that itch! DAYTIME (all PRN): 6-12 mo: Cetirizine 2.5 mg PO daily 12 mo – 2 yo: Cetirizine 2.5 mg PO daily, can increase to 2.5 mg q12h PRN 2-5 yo: Cetirizine 2.5 mg PO daily, can increase to 2.5 mg q12h or 5 mg PO daily PRN 6+ years: Cetirizine 5-10 mg PO daily
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NIGHT TIME (all PRN) Benadryl 0.5 mg/kg/dose PO qhs Hydroxyzine (Atarax) 0.5-1 mg/kg/dose PO qhs, max 25-50 mg single dose
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Antibiotics Crusty areas where infection suspected: Cephalexin 50 mg/kg/day PO divided TID or QID, max 1500 mg/day for 7-10 days If febrile or suspect systemic illness, may need admission
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Decolonizing Staph aureus Dilute bleach bath once weekly x 3 months Mix ½ cup bleach in full tub of water; or ¼ cup in ½ tub of water More dilute than chlorine exposure in a swimming pool Topical mupirocin 2% ointment to nares BID x 5-10 days if colonized with MRSA/recurrent impetigo
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Thank-you!
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References Nelson’s textbook of Pediatrics Zitelli’s atlas of pediatric physical diagnoses: 5th edition New Zealand website on Dermatology http://www.dermnetnz.org/ AAP Article on Eczema Nov 2014 http://pediatrics.aappublications.org/content/pediatrics/early/2014/11/18/peds.2014-2812.full.pdf