Managing Difficult Rashes Debra Shelby Ph D DNP

Managing Difficult Rashes Debra Shelby, Ph. D, DNP, FNP-BC, DNC, FACDNP, FAANP President and Founder National Academy of Dermatology Nurse Practitioners American College of Dermatology Nurse Practitioners Owner, Florida Specialty Medical Services, LLC and Dermstaffing Owner, National Institute for Dermatology

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Objectives: At the conclusion of the presentation, participants should be able to: § Discuss morphology and configuration of solitary & disseminated dermatoses. § Identify three commonly seen dermatoses. § Discuss two common diagnostic tools/procedures used for diagnosis. § Describe three frequently used drug classifications/ therapies used for treatment of dermatoses. § Discuss two complications with treatment of common dermatoses.

Conflict of Interest § Speaker reports no conflict of interest with this lecture

Terminology

Primary Skin Lesions § Macule: Small spot, different in color from surrounding § § § skin, that is neither elevated or depressed below skin surface. Papule: Small (<5 mm/1 cm diameter)* circumscribed solid elevation of skin. Plaque: Large (>5 mm/1 cm)* superficial lesion, often formed by confluence of papules. Nodule: Large (5 -20 mm) circumscribed solid skin elevation. Pustule: Small circumscribed skin elevation containing purulent material. Vesicle: Small (5 mm/1 cm)* circumscribed skin blister containing serum. *Textbook definitions vary from 5 mm-1 cm

Primary Skin Lesions Cont. § Wheal: Irregular elevated edematous skin area, which § § often changes size and shape. Bulla: Large (>5 mm) vesicle containing free fluid Cyst: Enclosed cavity with a membranous cavity lining, which contain fluid or semisolid matter. Tumor: Large nodule, which may be neoplastic Telangiectasia: Dilated superficial blood vessel. (Lookingbill & Marks, 2000) (Goldstein & Goldstein (1997), pg. 3)

Secondary Morphology § Scale: Superficial epidermal cells that are § § dead and cast off the skin. Erosion: Superficial focal loss of part of the epidermis; lesions usually heal without scarring Ulcer: Focal loss of the epidermis extending into the dermis; lesions may heal with scarring Fissure: Deep skin split extending into the dermis Crust: Dried exudate, a “scab”

Secondary Morphology Cont. § Erythema: Skin redness § Excoriation: Superficial, often linear, skin erosion § § § caused by scratching Atrophy: Decreased skin thickness due to skin thinning Scar: Abnormal fibrous tissue that replaces normal tissue after skin injury Edema: Swelling due to accumulation of water in tissue. (Goldstein & Goldstein (1997) , pg. 4)

Secondary Morphology Cont. § § Hyperpigmentation: Increased skin pigmentation Hypopigmentation: Decreased skin pigmentation Depigmentation: Total loss of pigmentation Lichenfication: Increased skin markings and thickening with induration secondary to chronic inflammation caused by scratching or other irritation § Hyperkeratosis: Abnormal skin thickening of the superficial layer of the epidermis. (Lookingbill & Marks, 2000) (Goldstein & Goldstein (1997), pg. 4)

Asking the Right Questions § § § § When did it start? What did it look like when it started? Where did it start? Where is it located now? What treatment have you used? What effect did they have? Are there symptoms? Are other family members affected? Have they ever had the rash before? (Goldstein & Goldstein (1997), pg. 5)

History § Review medical history § What are the patient’s social history § What medications are they taking. Anything new? § Does the patient have any allergies? § Is there a family history of skin diseases? § Assess patient’s education level and financial status (Goldstein & Goldstein (1997), pg. 5)

Physical § § § Distribution: Where are the lesions located? Primary features: What do they look like? Secondary features: Is there erythema, excoriation, crust, or pigmentary alterations? Diagnosis: Is the diagnosis certain or still need to be determined? Treatment: Record all treatment. Document sample medications. Patient education: Give patient handouts; document instructions given. (Goldstein & Goldstein (1997), pg. 5)

Diagnosing § Lesions may be differentiated by their morphologic characteristics § Lesions may be differentiated by their characteristic distribution § Lesions are often seen in a particular age (Goldstein & Goldstein (1997), pg. 7) (Lookingbill & Marks, 2000)

Classic Distribution of Common Skin Disorders § Atopic Dermatitis: Extensor surfaces in infants; § § flexural areas in young children and adults Hand Foot Eczema: Palms, soles Psoriasis: Extensor surfaces, posterior scalp, sacral area and intertriginous areas. Scabies: Finger webs, wrists, axilla, waist, groin, and feet Seborrhea: Scalp, ears, central face, chest, and groin (Goldstein & Goldstein, 1997) (Lookingbill & Marks (2000), pg. 7)

Diagnostic Tests § Potassium /hydroxide Prep (KOH): - Used to identify fungus or yeast from epidermal scrapings § Fungal Cultures: Useful in hair or nail infections. Can be used for skin. § Bacterial Cultures § Scabies test § Tzanck Smear: Herpes infections § Wood’s Lamp Examination: Tinea, dyschromia, erythrasma § PAS: Periodic acid-Schiff

Dermatologic Therapies

Most Common Drug Therapies § Topical Glucocorticosteriods § Antibiotics § Antifungals § Immunomodulators § Biologics Don’t forget: With some rashes, effective emollients are as important as drug therapies.

Dermatologic Therapies § Ointments: Consists of mainly water suspended in oil. § § § Generally the most potent vehicle because of their occlusive effect. Creams: Semisolid emulsions of oil in 20% to 50% water. Most cosmetically appealing Lotions: Powder-in-water preparations. Least potent, but are useful in hairy areas and conditions with large surface areas. Solutions: Consist of water mixed with various medications or substances. Used for soaks and open, wet dressings Gels: Oil-in-water emulsions with alcohol in the base. Combines the best therapeutic advantages of ointments with the best cosmetic advantages of creams Foams: Alcohol based, great for large areas and hairy locations (Goldstein & Goldstein (1997), pg. 11)

Topical Glucocorticosteroids § Class I: Superpotent Examples: Clobetasol proprionate ointment, cream 0. 5% Betamethasone diproprionate gel and ointment 0. 05% Class II: High Potency Examples: Betamethasone diproprionate AF cream 0. 05%, Fluocinonide gel, ointment and cream 0. 05% Class III: High Potency Examples: Triamcinolone acetonide cream 0. 5% Betamethasone valerate ointment 0. 1% (Bolognia, Jorizzo, & Rapini (2003), p. 1882)

Topical Glucocorticosteroids cont. § Class 4: Medium Potency Examples: Fluticasone proprionate cream 0. 05%, Triamcinolone acetonide (Kenolog)cream 0. 1% Class 5: Medium Potency Examples: Hydrocortisone butyrate cream 0. 1% Triamcinolone acetonide lotion Class 6: Low Potency Examples: Desonide cream 0. 05% Fluocinolone acetonide cream 0. 01% (Bolognia, Jorizzo & Rapini (2003), p. 1882)

Topical Gluticocorticosteroids cont. § Class 7: Low Potency § Topicals with hydrocortisone, dexamethasone and prednisolone Remember: § Brand names may be higher potency than generic § Vehicle can affect potency § Many topical medications have the same name, but different strength that can change class potency. Make sure you check strength (Bolognia, Jorizzo, & Rapini (2003), pg 1882)

Papulosquamous Diseases

Eczema § Eczema is a broad term to describe an array of § § inflammatory skin disorders Classified by several classification schemes: Cause, location, degree of involvement, or a generalized condition Acute: severe, with edema, vesicles, and bullae Subacute: Scaling plaques Chronic: Thickened accentuated skin markings called lichenfication (Lookingbill & Marks, 2000) (Goldstein & Golstein (1997), pg. 157)

Atopic Dermatitis § Very pruritic skin disorder involving cutaneous § § § § hypersensitivity Usually begins in early infancy after 6 weeks of age Variable symptoms Associated with decreased cellular immunity Often becomes colonized with Staph. aureus Extensor surfaces and face of children Flexural areas in children and adults Plaques, papules, erythema, scale, excoriations, fissures, crust, and lichenfication (Lookingbill & Marks, 2000) (Goldstein & Golstein (1997), pg. 157)

Contact Dermatitis § Pruritic, reactionary skin disorder that results when a particular substance comes in contact with the skin § Second most common cause of occupational disability § Contact dermatitis occurs when an allergen or related compound causes a delayed type of hypersensitivity reaction on re-exposure (poison ivy) (Lookingbill & Marks, 2000) (Goldstein & Golstein (1997), pg. 162)

Treatments § § § Find source of allergy Corticosteroids (careful with vehicle selection) Pimecrolimus (Elidel) Tacrolimus (Protopic) Lactic acid (avoid in inflamed skin) Hydration: Emollients, protective barriers, hyaluronic acid, and petrolatum. (careful with vehicle selection and ingredients) -Vanicream, Vanicream lite lotion, Vanicream bar, Vanicream ointment. § Mild cleansers, laundry soap, no fabric softner § Narrow band UVB § Treat secondary bacterial or fungal infections

Irritant Dermatitis § Irritant dermatitis occurs secondary to any non-allergic skin irritation resulting from exposure to an offending agent, either with initial or repeated exposures (hand washing, bleach, moisture, friction)

Irritant Dermatitis Treatment § Find source of irritation or friction § Intertriginous: Make sure you biopsy to rule out Inverse § § § § § psoriasis Good hygiene Control moisture: Knitted polyester fabric With or without silver (Inter. Dry Ag, Maxorb Ag) Control friction Treat fungal and bacterial infections Corticosteroids (careful with vehicle selection and potency) Pimecrolimus (Elidel) Tacrolimus (Protopic) Skin barriers

Stasis Dermatitis § Chronic eczematous process resulting from suboptimal § § lower extremity circulation and chronic venous insufficiency More common in people over 50 Higher incidence in women than men Predisposing conditions: Varicose veins, cardiac failure, surgery, trauma, thrombophlebitis, and hypoalbuminemia. Early signs include hyperpigmentation caused by leakage of blood into the dermis and its subsequent breakdown into hemosiderin. (Golstein & Goldstein (1997), p. 169

Treatments This is a collaborative team effort! PCP, derm, wound care, and vascular surgeon § Compression: support hose, elastic wraps, unna boot (after DVT ruled out!) § Diuretics (with the presence of pitting edema) § Elevate legs § Corticosteroids § Emollients: Careful selection § Pharmacology: Antibiotics, prednisone, Diosmin and Pentoxifylline § Low salt diet § Restrict sitting and standing for long periods § Vascular Surgeon

Psoriasis § Chronic, recurrent, hyperproliferative § § § inflammatory disorder of unknown cause Affects 3 -5 million people in the U. S. Initially appears most commonly in people younger than 20 years old, peak incidence occurs around 22. 5 years, but can occur at any age, even after age 60 Characterized by erythematous plaques with thick, adherent, silvery scales. ( Wolff & Johnson, 2005) (Lookingbill & Marks, 2000) (Goldstein & Golstein. 1997)

Psoriasis cont. § Auspitz sign: Punctate bleeding points from capillaries close to the top layer of skin after one peels off the scale § Distribution: Extensor surfaces, typically sparing the face. (Goldstein & Golstein. 1997)

Treatments § Topical Corticosteroids § NO PREDNISONE: REBOUND § Calcipotriene (Dovonex cream, ointment, § § § scalp solution) Immunomodulators Biologics Tar PUVA, narrow band UVB Methotrexate, Soriatane

Inverse Psoriasis § Skin folds: Axilla, breasts, genitals, groin and buttocks § Biopsy to confirm when other treatments are ineffective. § Control moisture: Knitted polyester fabric (Inter. Dry, Maxorb), Castellani’s Paint § Treatment same as psoriasis. Careful with topical steroids in intertriginous areas.

Fungal Infections

Fungal Infections § Dermatophyte v. yeast § Hyphae v. hyphae and spores § Look for erythematous plaques with scale, central clearing, and well-demarcated borders. § Use topical antifungals § Lamisil (Terbinafine), Sporonox (Itraconazole) and Ketoconazole (Lookingbill & Marks, 2000) (Goldstein & Golstein. 1997)

Avoid Pitfalls § Biopsy and get fungal cultures § Make sure you treat with right antifungal medication § Past history of steroids? § Majocchi’s granuloma: Deep follicular fungal infection § Remember: Topical only reach so far into the dermis. Deep tissue needs systemic antifungals.

Tinea Cruris § Dermatophyte infection of the groin § Scrotum most often spared § Characterized by pruritus or burning sensations § Erythema, scale, central clearing, and well defined borders § KOH, antifungals (Lookingbill & Marks, 2000) (Goldstein & Golstein. 1997)

Tinea Manus § Dermatophyte infection of hand nails § Usually unilateral, but is virtually always associated with bilateral involvement of the hands § Plaques, scale, erythema, desquamation § KOH § Antifungals and oral agents (Lookingbill & Marks, 2000) (Goldstein & Golstein. 1997)

Tinea Pedis § Dermatophyte infection of the feet. § Erythema, scale, maceration, and vesicles § KOH § Antifungals, topical, and oral § Treat secondary bacterial infections

Tinea Versicolor § Yeast infection caused by pitysporum orbiculare § Hyphae and spores § Produces azelaic acid which inhibits pigment transfer to keratinocytes § Predisposing factors include hot, humid weather § Selenium sulfide, Nizoral (Ketoconazole) (Lookingbill & Marks, 2000) (Goldstein & Golstein (1997), pg. 107)

Candidiasis § Seen with intertrigo (irritant derm) § Caused by candida § Skin folds, under breasts, abdominal folds, groin, rectum, axillae, and fingerwebs. Scrotum is involved § Beefy red lesions with satellite erythematous papules and/or pustules § KOH negative (pseudohyphae and spores) § Selenium sulfide, Nizoral (Ketoconazole), econazole (Lookingbill & Marks, 2000) (Goldstein & Golstein (1997), pg. 107)

Bacterial Infections

Erythrasma § Superficial infection of any intertriginous area § Caused by Corynebacterium minutissimun § Common in hot humid climates § Well-defined, brown patches with scale § Pruritus § Wood’s lamp reveals coral-red fluorescence (Golstein & Goldstein (1997), pg. 302)

Treatments § Topical antibiotics: Benzoyl peroxide, erythromycin, clindamycin, mupirocin ointment or cream § Oral antibiotics: Erythromycin, Doxycycline, or Clarithromycin § Good hygiene

Folliculitis § Array of pustular infections that involve the hair § § § follicle Superficial or deep Staph aureus most common, but can be caused by pseudomonas and pitysporum Deep: - Furuncle- deep inflammatory nodule - Carbuncle- aggregation of furuncles (Lookingbill & Marks, 2000) (Goldstein & Golstein. 1997)

Other Causes § Herpes: Herpes Simplex shaving near cold sore § Gram negative § Lupus § Pseudo folliculitis § Immune -Eosinophilic Pustular: associated with HIV -Eosinophilic folliculitis: rare autoimmune § Oil folliculitis

Treatment § Antibiotics (oral and topical): Doxycycline, minocycline. Clindamycin, erythromycin § Benzoyl peroxide § Dapsone gel § Retinoids § Antifungals § Isotretinoin

A word on MRSA § Drain lesions and irrigate § Culture and Sensitivity § Treat nares: Mupirocin ointment and gentamicin ointment § Systemic and topical § Washes: Hibiclens; caution ototoxic Avoid face, head and genitals! Give very clear written instructions to patient. Be aware of allergic reactions and avoid on inflammatory dermatoses.

Thank You Questions?