Angie L. Goeser
LEARNING OBJECTIVES
Upon completion of the chapter, the reader will be able to:
1. Describe the pathophysiology of common skin disorders.
2. Assess the signs and symptoms of common skin disorders in a presenting patient.
3. List the goals of treatment for patients with common skin disorders.
4. Select appropriate nonpharmacologic and pharmacologic treatment regimens for patients presenting with common skin disorders.
5. Identify adverse effects that may result from pharmacologic agents used in the treatment of common skin disorders.
6. Develop a monitoring plan which will assess the safety and efficacy of the overall disease state management of common skin disorders.
7. Create educational information for patients about common skin disorders, including appropriate self-management, available drug treatment options and anticipated therapeutic responses.
KEY CONCEPTS
The development of acne lesions results from four pathogenic factors which include excess sebum production, keratinization, bacterial growth, and inflammation.
The treatment goals for acne vulgaris are to eliminate existing lesions and prevent new lesions from developing, as well as to decrease discomfort and the incidence of scarring.
Acne is categorized as mild, moderate, or severe based on lesion type and severity and successful treatment approaches are developed based on these categories.
Irritant contact dermatitis results from first-time exposures to irritating substances such as soaps, plants, cleaning solutions, or solvents. Allergic contact dermatitis occurs after an initial sensitivity and further exposure to allergenic substances, including poison ivy, latex and certain types of metals.
The initial treatment goal of contact dermatitis is identifying the causative substance and eliminating its exposure. The second treatment goal is symptom relief.
Although many factors contribute to the etiology of diaper rash, it is most likely the result of prolonged contact of the skin with urine and feces in the diaper.
The primary goal in the treatment of diaper rash is prevention and is most often accomplished through frequent diaper changes.
When a diaper rash is already present, repairing the damaged skin, relieving discomfort and preventing infection are important factors to consider when developing an effective treatment regimen.
INTRODUCTION
The skin is the largest organ of the human body. One of its most important functions is to assist the immune system by serving as a barrier that protects underlying structures from trauma, infection and exposure to harmful environmental elements. The skin also holds in place essential organs and fluids necessary for life. Any significant injury to this outer protective layer may potentially compromise an individual’s overall health.
Several thousand skin disorders are currently documented, and many patients will seek the assistance of a health care provider when a complication with their skin develops. Others will utilize methods of self-care to effectively treat their symptoms. Some skin problems, such as mild acne or diaper rash, may be successfully treated with over-the-counter medications and lifestyle modifications. However, if left untreated or treated inadequately, these seemingly simple disorders can worsen and require more advanced care.
As health care providers, it is important to be familiar with the diagnosis and treatment of skin disorders. This chapter discusses acne vulgaris, contact dermatitis (irritant and allergic), and diaper dermatitis; other common skin and soft tissue infections and superficial fungal infections are discussed in Chapters 73 and 83, respectively. Providing patients with appropriate therapy options, as well as patient education on methods of treatment and prevention, will assist the successful resolution of many common skin disorders.
ACNE VULGARIS
Acne vulgaris, an inflammatory skin disorder of the pilosebaceous units of the skin, is the most common dermatologic reason for physician visits in the United States.1 Although most commonly seen on the face, acne can also present on the chest, back, neck and shoulders (See Fig. 65–1).2 While generally a self-limiting condition, long-term physical complications of acne may include extensive scarring and psychological distress.1,3
EPIDEMIOLOGY AND ETIOLOGY
With an estimated 40 to 50 million people affected, acne vulgaris is the number one skin disease in the United States.3,4 While acne affects approximately 85% of adolescents and adults aged 12 to 25 years, the disease can develop or recur in adults aged 30 to 50 years.5 The prevalence of acne among Whites, African Americans, Hispanics, and Asians is similar, with acne occurring more often in males during adolescence and females during adulthood.6,7
FIGURE 65–1. A spectrum of acne lesions is seen on the face of a 17-year-old male: comedones, papules, pustules, and erythematous macules and scars at the site of resolving lesions. The patient was successfully treated with a 4-month course of isotretinoin; there was no recurrence over the next 5 years. (From Wolff K, Johnson RA. Disorders of sebaceous and apocrine glands. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 5.) (From Ref. 2.)
PATHOPHYSIOLOGY
The development of acne lesions results from four pathogenic factors: excess sebum production, keratinization, bacterial growth and inflammation.3,7
The pilosebaceous unit of the skin consists of a hair follicle and the surrounding sebaceous glands. An initial acne lesion called a comedo forms when there is a blockage in the pilosebaceous unit.8
Sebum is released by the sebaceous glands and naturally maintains hair and skin hydration. An increase in androgen levels, especially during puberty, can cause an increase in the size of the sebaceous gland and the production of abnormally high levels of sebum within those glands. This excess sebum can result in plugged follicles and acne formation.
Keratinization, the sloughing of epithelial cells in the hair follicle, is also a natural process. In acne, however, hyperkeratinization occurs and causes increased adhesiveness of the sloughed cells. Accumulation of these cells clogs the hair follicle, blocks the flow of sebum and forms an acne lesion called an open comedo or “blackhead.”
Propionobacterium acnes (P. acnes), an anaerobic organism , is also found in the normal flora of the skin. This bacteria proliferates in the mixture of sebum and keratinocytes and can result in an inflammatory response producing a closed comedo or “whitehead.” More severe acne lesions such as pustules, papules, and nodules also form with inflammatory acne and result in significant scarring if treated inadequately (see Fig. 65–2 for various stages of acne development).
TREATMENT
Desired Outcomes and Goals
While eliminating existing lesions and preventing the development of new lesions are primary goals of acne therapy, secondary goals include relieving pain or discomfort and preventing permanent scarring.8 In addition, acne can cause patients a significant amount of stress, anxiety, frustration, embarrassment, and even depression.10 Because of these psychological symptoms, treatment compliance and patient education on both physical and psychological aspects of this skin disorder are also imperative.
General Approach to Treatment
Acne is categorized as mild, moderate, or severe based on the lesion type and lesion severity (see Table 65-1). Successful treatment approaches are developed based on these categories, as well as any previous treatment information presented by the patient. Improvement of symptoms following treatment occurs gradually, sometimes taking 6 to 8 weeks for results to be physically apparent. 8 Patients need to be educated on continual treatment compliance during this time and not get discouraged if acne lesions appear to worsen before getting better during the initial 2 to 3 weeks of therapy.11
FIGURE 65–2. Stages of acne. A. Normal follicle; B. open comedo (blackhead); C. closed comedo (whitehead); D. papule; E. pustule. (From Ref. 9. Copyright “Hartsock M. Medical illustrations. Cincinnati, OH: The Medical Art Company.”)
Nonpharmacologic Therapy
There is significant variance in the clinical benefit of many nonpharmacologic interventions for acne vulgaris. Among nondrug treatment alternatives, mild, noncomedogenic facial soap used twice daily, as well as the avoidance of oily skin products and the avoidance of manipulating or squeezing lesions are helpful self-treatment recommendations.
Clinical Presentation and Diagnosis of Acne
Acne lesions are most often seen on the face, but can also present on the chest, back, neck, and shoulders and are described as either noninflammatory or inflammatory. In addition, severe inflammatory lesions can lead to scarring and hyperpigmentation.
Noninflammatory Lesions
Open comedo or “blackhead”: a plugged follicle of sebum, keratinocytes, and bacteria that protrudes from the surface of the skin and appears black or brown in color. Although dark in color, blackheads do not indicate the presence of dirt, but rather, an accumulation of melanin.
Closed comedo or “whitehead”: a plugged follicle of sebum, keratinocytes, and bacteria that remains beneath the surface of the skin. Closed comedos usually appear as small white bumps about 1 to 2 mm in diameter.
Inflammatory Lesions
Papules: Solid, elevated lesion less than 0.5 cm in diameter Pustules: Vesicles filled with purulent fluid less than 0.5 cm in diameter
Nodules: Lesions greater than 0.5 cm in both width and depth
Cysts: Nodules filled with a fluid or semisolid which can be expressed
Scars
Inflammatory acne can result in permanent scarring that ranges from small depressed pits to large elevated blemishes.
Hyperpigmentation
Inflammatory acne may result in hyperpigmentation of the skin that can last for weeks to months.
Diagnosis
The diagnosis of acne vulgaris is clinical. Lesion cultures may be warranted when treatment regimens fail to rule out other skin infections.
Table 65–1 Predominance of Acne Lesion Type by Acne Severity
Pharmacologic Therapy
Topical Agents
Benzoyl Peroxide
Benzoyl peroxide is easy to use and recommended as first-line therapy in the treatment of mild to moderate noninflammatory acne. Benzoyl peroxide has a comedolytic effect that increases the rate of epithelial cell turnover and helps to unclog blocked pores. It also has antibacterial activity against P. acnes, which appears to be the main reason for its effectiveness.13
Benzoyl peroxide is available with or without a prescription and remains the most commonly purchased over-the-counter topical treatment for acne.12 It is available in concentrations ranging from 1% to 10% in various formulations including creams, lotions, gels, and facial washes.
Adverse effects commonly reported with benzoyl peroxide are dryness, irritation, redness, and stinging of the skin. Reducing the incidence of these effects can be achieved by beginning a treatment regimen with the lowest strength and titrating up to higher effective strengths over several weeks if needed. In addition, newer formulations of benzoyl peroxide are combined with moisturizers to help decrease skin redness and irritation.13 A disadvantage of the agent is that it can bleach and discolor hair and fabrics that come into contact.12
A typical regimen for benzoyl peroxide is to apply the product to clean, dry skin no more than two times a day. The strength and dosage form selected may vary from patient to patient depending on acne severity and the sensitivity of the patient’s skin. Since gel preparations are the most potent dosage form, patients with dry or overly sensitive skin should be recommended a milder cream, lotion, or facial wash.3 If severe irritation or allergic reaction develops, benzoyl peroxide use should be discontinued.
Retinoids
Retinoids, which are highly effective in the treatment of acne, stimulate epithelial cell turnover and aid in unclogging blocked pores. Retinoids also exhibit anti-inflammatory properties through the inhibition of neutrophil and monocyte chemotaxis.8 Because of these comedolytic and anti-inflammatory effects, topical retinoids are recommended as first-line treatment for mild to moderate comedonal and inflammatory acne.3 While success is seen with monotherapy, using a retinoid in combination with benzoyl peroxide or topical antibacterials is also an appropriate and effective therapeutic treatment option.3Tretinoin, adapalene, and tazarotene are topical retinoids available for use in the treatment of acne. Table 65–2 describes the strengths and formulations of these agents.
Transient erythema, irritation, dryness, and peeling at the site of application are all common adverse effects. Newer retinoids formulated in either a microsphere gel (Retin-A Micro) or an aqueous-based gel (Atralin) appear to cause less initial skin discomfort than older agents in this class.13 Photosensitivity can also occur with retinoid use, causing increased skin irritation and redness.14
The topical retinoid selected should be applied once daily at bedtime, beginning with a low potency formulation. Increased strengths are then initiated according to treatment results and tolerance. Patients should be advised that a worsening of acne symptoms generally occurs in the first few weeks of therapy, with lesion improvement occurring in 3 to 4 months.16 The use of topical retinoids should be avoided in children less than 12 years old and in pregnant women.14
Antibacterials
Topical antibacterials directly suppress P. acnes and are also first-line agents used in the treatment of mild to moderate inflammatory acne.3,16
Clindamycin 1% and erythromycin 2% preparations, applied once or twice daily, have similar effects and are the most commonly prescribed topical antibacterial agents.17 These agents, as well as sodium sulfacetamide, are available in various formulations for the treatment of acne.
Adverse effects are generally mild and include dryness, erythema, and itching.18 Although rare and seen most often with oral therapy, pseudomembranous colitis can occur with the prolonged use of topical clindamycin.19 As with any antibacterial agent, the possibility of resistance exists with the use of topical antibiotics. However, coadministration of clindamycin or erythromycin and benzoyl peroxide has shown to decrease the incidence of resistance, as well as to improve symptoms of mild to moderate inflammatory acne.7,20
Azelaic Acid
With antibacterial and anti-inflammatory properties, and the ability to stabilize keratinization, azelaic acid is an effective alternative in the treatment of mild to moderate acne in patients who cannot tolerate benzoyl peroxide or topical retinoids.3,21 It can also even out skin tone that may prove effective in patients who are prone to postinflammatory hyperpigmentation resulting from acne.22
Adverse effects are minimal and transient with erythema and skin irritation most common.16,21
Azelaic acid 20% cream should be applied twice daily with improvement of symptoms seen in 1 to 2 months.21
Keratolytics
Sulfur, resorcinol, and salicylic acid are not as effective as other topical agents, but can be used as second-line therapies in the treatment of mild to moderate acne.12
Table 65–2 Topical Retinoids Available for the Treatment of Acne
While these agents may cause less skin irritation than benzoyl peroxide or the topical retinoids, several disadvantages exist. Sulfur preparations produce an unpleasant odor when applied to the skin, while resorcinol may cause brown scaling. And although rare, the possibility of salicylism exists with continual salicylic acid use.3,12
Oral Agent
Antibacterials
Moderate to severe acne can be effectively treated with oral antibiotics, especially when treatment with topical therapy has failed. Because of their ability to decrease P. acnes colonization, oral antibiotics can prevent acne lesions from developing.8 Improvement of symptoms is generally evident at 6 to 10 weeks, with maximum benefits occurring after 6 months of therapy.23
Tetracycline, doxycycline, and minocycline are the most commonly prescribed oral antibiotics for acne. Erythromycin and clindamycin are appropriate second-line agents for use when patients cannot tolerate or have developed resistance to tetracycline or its derivatives.3 Other antibiotics, including trimethoprim (± sulfamethoxazole) and azithromycin are also effective agents to use when patients fail or are unable to tolerate conventional treatment.7 (See Table 65–3 for antibiotic dosing guidelines.)
Adverse effects with the tetracyclines include GI upset, drug interactions with dairy products, antacids and iron, and phototoxicity. Minocycline can also cause vestibular complications (headache, dizziness) and skin discoloration that is not typical with tetracycline and doxycycline.16
Although their effectiveness is similar to the tetracyclines, erythromycin, and clindamycin use is often limited due to their potential adverse outcomes. Erythromycin has increased resistance to P. acnes and a high incidence of GI intolerance, while clindamycin causes diarrhea and the risk of developing pseudomembranous colitis with long term use.3,8
Isotretinoin
Isotretinoin is effective in up to 80% of patients with severe nodulocystic acne who are unresponsive to other topical and oral treatment regimens.8,23,24 Isotretinoin works on the four pathogenic factors that contribute to acne development and can produce acne remission rates of up to several years.
Adverse effects with the use of isotretinoin are frequent and generally dose-related. About 90% of patients experience drying of the mucosa of the mouth, eyes, and nose.3 Drying, peeling, and pruritus of the facial skin is also likely. Increases in cholesterol and triglyceride levels have been reported with isotretinoin use; therefore, it is recommended to monitor liver function and serum lipids at baseline, 4 and 8 weeks of therapy to identify any complications. Other serious adverse effects from this medication include increased creatine phosphokinase, increased blood glucose, teratogenicity, photosensitivity, muscle pain, suicidality, and depression.3 Table 65–4 lists the common adverse effects from isotretinoin therapy and management strategies for those symptoms.
Because it is teratogenic and classified as pregnancy category X, the FDA mandates an online registry program called iPledge to ensure that females do not become pregnant while taking isotretinoin. Wholesalers, pharmacies, doctors, and patients must be registered in the iPledge computer-based system in order to control the distribution, prescribing, and dispensing of isotretinoin. Two negative pregnancy tests prior to initiating therapy and one negative pregnancy test each month thereafter must be obtained and confirmed in the system before a prescription can be dispensed to female patients of child-bearing potential. These patients must also commit to effective measures of birth control during the course of isotretinoin therapy. Contact the program at their website: https://www.ipledgeprogram.com/ for further details.
Table 65–3 Oral Agents Used in the Treatment of Moderate to Severe Acne
Table 65–4 Principle Adverse Effects of Oral Isotretinoin
Patient Encounter 1
A 14-year-old female high school student presents to your clinic with complaints of worsening acne. Upon visual examination, you see that she has four pustules on her chin, two pustules on her forehead, and numerous open and closed comedones on her nose and cheeks. After interviewing the patient, you conclude that her acne lesions are moderately painful and make her feel embarrassed about going to school with so many “zits.” She says that she began to have occasional acne at the age of 12, but over the past 6 months symptoms have worsened and states that she always has four to six lesions present on her face. The patient appears to be a healthy teenager who says that she eats well and is very athletic.
What reported symptoms support the diagnosis of acne?
What other information would you obtain from this patient before creating a treatment plan for her?
Describe your treatment goals for this patient.
What nonpharmacologic and pharmacologic treatment options are available for this patient?
Given the information presented, develop a treatment regimen for this patient including (a) a statement of the problem, (b) a patient-specific therapeutic plan, and (c) monitoring parameters to assess efficacy and safety.
Initial dose ranges for treatment are 0.5 to 1 mg/kg daily in two divided doses, with beneficial results generally reported at total daily doses of 120 to 150 mg/day.3
Oral Contraceptives
Oral contraceptives are a valuable second-line treatment option for moderate to severe acne in female patients. While many contraceptives are effective, three agents (Yaz, Estrostep, and Ortho Tri-Cyclen) have been FDA approved for the treatment of acne.25 Oral contraceptives decrease the production of androgens by the ovaries, which in turn leads to a decrease in sebum production.3,16
Adverse effects include nausea, weight gain, breast tenderness and breakthrough bleeding. Oral contraceptives have also been associated with an increased incidence of thromboembolic disease, particularly in women who use tobacco products or have other risk factors for thromboembolism. The development of these complications is significantly reduced when low dose estrogen formulations of oral contraceptives are used.3
Other Agents
Although use is infrequent, several other agents are available as second-or third-line treatment options for acne when first-line therapies fail and include the following3,7 :
• Corticosteroids
• Chemical peels
Patient Care and Monitoring: Acne
1. Assess patient symptoms and the presence of acne lesions. Determine severity of acne: mild, moderate or severe.
2. Review patient history to determine treatment regimens that have been used in the past, including nonprescription, prescription, and herbal medications.
3. Obtain patient’s allergy status.
4. Develop a treatment plan appropriate for improvement of acne.
5. Discuss any monitoring parameters that may be necessary throughout the course of therapy.
6. Provide patient education on acne and its treatment:
a. What is acne and how does it develop?
b. Physical and psychological complications that can result from acne.
c. What drug and nondrug therapies are available for treatment?
d. Describe the possible side effects of drug therapy.
e. Emphasize the importance of treatment regimen compliance to ensure positive results.
FIGURE 65–3. Algorithms for acne treatment. (From Ref. 3.)
• Surgical extraction
• Phototherapy/photodynamic therapy
• Laser treatments
Figure 65–3 shows useful algorithms for the effective treatment of the various stages of acne.
OUTCOME EVALUATION
Depending on severity, complete resolution of acne may take weeks to months. Monitor patients after 6 weeks of pharmacologic therapy for any improvement of signs and symptoms12 :
• Decreased number of lesions
• Decreased severity of lesions
• Relief of pain/irritation
If no improvement is reported or symptoms have worsened, patients should be reevaluated and a change in the current treatment regimen may be necessary.
Educate patients on the possibility of adverse effects. Consider a change in therapy if a patient experiences effects that are not tolerated or are considered a compromise to their health.
CONTACT DERMATITIS
Contact dermatitis is a condition in which exposure to an offending substance produces inflammation, erythema, and pruritus of the skin.26 More specifically, contact dermatitis can be divided into either irritant or allergic forms.26,27 Irritant contact dermatitis results from first-time exposure to irritating substances such as soaps, plants, cleaning solutions, or solvents. Allergic contact dermatitis occurs after an initial sensitivity and further exposure to allergenic substances, including poison ivy, latex, and certain types of metal.28 (See Figs. 65–4 and 65–5.) Table 65–5 lists agents commonly responsible for irritant and allergic contact dermatitis. While generally occurring on the exposed skin, such as the hands and face, contact dermatitis can appear anywhere on the body.26 Although most cases are easily treated, contact dermatitis remains an uncomfortable and sometimes embarrassing skin condition.
EPIDEMIOLOGY AND ETIOLOGY
Contact dermatitis is a common reason for dermatology referrals and constitutes up to 90% of all workers’ compensation claims for dermatologic conditions. Although most often seen in adults, contact dermatitis can affect all age groups, with females at slightly greater risk than males.29
FIGURE 65–4. Irritant contact dermatitis. Erythema and edema with spared areas on the back at sites in contact with an irritant in a 30-year-old male. (From Wolff K, Johnson RA. Eczema/dermatitis. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 20.)
FIGURE 65–5. Allergic contact dermatitis of the hand: chromates. Confluent papules, vesicles, erosions, and crusts on the dorsum of the left hand in a construction worker who was allergic to chromates. (From Wolff K, Johnson RA. Eczema/dermatitis. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 27.)
PATHOPHYSIOLOGY
Irritant contact dermatitis is not the result of an immunologic process, but rather occurs from direct injury to the skin. An irritating agent comes into contact with the skin, damages the protective layers of the epidermis and can cause erythema, the formation of vesicles and pruritus.26,30,31 Symptoms occur within minutes to hours of exposure and begin to heal soon after removal of the offending substance.28
Allergic contact dermatitis is a delayed hypersensitivity reaction.31 Upon initial exposure, a substance penetrates the skin, binds to a protein and develops into sensitizing antigens. Subsequent exposures to that substance will then elicit an allergic reaction.26,30,31 Symptoms of allergic contact dermatitis are similar to those of the irritant type, but may take several hours to several days to develop following reexposure.26,27
TREATMENT
Desired Outcomes and Goals
Identifying the causative substance and eliminating its exposure is the initial treatment goal for contact dermatitis. Although physical symptoms can develop almost immediately after contact, removal of the offending agent will improve existing symptoms and prevent the occurrence of further complications. The second treatment goal is symptom relief. Since inflammation and pruritus, as well as lesion formation, are likely to result from contact dermatitis, appropriate selection of nonpharmacologic and pharmacologic agents for these symptoms is necessary.
Table 65–5 Common Agents Causing Contact Dermatitis
Irritant Contact Dermatitis
Soaps
Detergents
Cosmetics
Solvents
Acid, mild or strong
Alkali, mild, or strong
Allergic Contact Dermatitis
Plant resins, poison ivy, poison oak, sumac
Metals (nickel or gold in jewelry)
Latex and rubber
Cigarette smoke
Local anesthetics (lidocaine, benzocaine)
Clinical Presentation and Diagnosis of Contact Dermatitis
Contact dermatitis is generally confined to the area of contact, but in a highly sensitive person, a widespread or even generalized eruption may occur. Contact dermatitis is divided into two forms—irritant and allergic. Both forms may include, but are not limited to:
• Erythema
• Pruritus
• Vesicles
• Papules
• Crusts
• Burning
Irritant Form
The irritant form usually presents within hours of exposure and the rash is often localized. Irritant contact dermatitis may also result in fissuring and scaling.
Allergic Form
The allergic form can take several days to present and the condition may extend beyond the borders of the region exposed. Allergic contact dermatitis may also include oozing pustules and skin erosion.
Diagnosis
When the causative agent is known, the diagnosis of contact dermatitis is clinical. Patch testing is done if the allergens are unknown and is usually performed several weeks after the resolution of the original dermatitis.
Nonpharmacologic Therapy
In many cases, contact dermatitis may not require medical treatment at all. Nondrug therapy for contact dermatitis is aimed at relieving pruritus and maintaining skin hydration.28 • Effective agents used for this include the following:26,28
• Colloidal oatmeal baths
• Cool or tepid soapless showers
• Cool, moist compresses applied to the area for 30 minutes three times a day
• Emollients or lubricants applied to the area after bathing (mineral oil, petrolatum)
Pharmacologic Therapy
Astringents
The drying effect of astringents will decrease oozing from lesions and relieve itching.26,27 Due to their ability to cause blood vessel constriction, astringents can also decrease inflammation. Aluminum acetate (Burow’s solution), calamine, and witch hazel are safe and effective.26 Patients apply solutions as a compress for 15 to 30 minutes two to four times a day.
Adverse effects reported with these agents are minimal and include drying and tightening of the skin. Because of this, their use should be limited to no more than 7 days.26,27,29
Topical Steroids
Erythema, inflammation, pain, and itching caused by contact dermatitis can be effectively treated with topically applied corticosteroids. With such a wide range of products and potencies, an appropriate steroid selection is based on severity and location of lesions (See Table 65-6 for a list of topical steroids and potencies.) Higher potency preparations are used in areas where penetration is poor, such as the elbows and knees. Lower potency products should be reserved for areas of higher penetration, such as the face, axillae, and groin. Low potency steroids are also recommended for the treatment of infants and children.33,34
Adverse effects from topical steroids are usually related to the potency of the steroid, frequency of application, duration of therapy and the site of application. Skin atrophy, hypopigmentation, striae and steroid-induced acne are all possible side effects associated with long-term use.33,34
Topical steroids are typically applied two to four times daily. As improvement begins, maintenance therapy should be limited to the lowest strength steroid that continues to control the condition. Once symptoms are completely resolved, use should be discontinued.
Antihistamines
Whether due to their antihistaminic activity or their sedative side effects, pruritus caused by contact dermatitis can be relieved with the use of sedating oral antihistamines such as diphenhydramine or hydroxyzine. Topical antihistamines are available, but use is limited due to their high-sensitizing potential.26,33
In addition to sedation, many oral antihistamines can cause hypotension, dizziness, blurred vision, and confusion.29
Diphenhydramine and hydroxyzine can be safely administered to children older than 2 years and adults. Table 65–7 outlines the recommended doses for these medications.
OUTCOME EVALUATION
With adequate treatment, most cases of contact dermatitis should improve within 7 days. Complete resolution of symptoms may take up to 3 weeks.26 If a patient experiences severe symptoms associated with fever or difficulty breathing, they should be instructed to seek medical attention immediately. Furthermore, patients should return to their health care provider if any of the following occur:
• Rash has not improved or has worsened after several days of treatment
• Rash has increased in size or has spread to other locations
• Patient is experiencing adverse effects from the treatment regimen
Table 65–6 Topical Steroids to Treat Contact Dermatitis
Table 65–7 Oral Antihistamines Used fo
Patient Encounter 2
A 45-year-old female presents to a pharmacy with complaints of itching and wants a recommendation to treat it. Upon visual examination you see that she has erythematous papules on both legs. After further questioning, you learn that she has recently spent a great deal of time outside at a family picnic. She states that the picnic was in a wooded area near her home and that she and several others went on a short hike that day. She states that she was wearing shorts and “probably” came into contact with the grasses and weeds that lined the hiking trail. The rash appeared the same day as the picnic and she says that it seems to have spread since it first developed. From the information she has presented, you conclude that she has been exposed to poison ivy.
What information supports the possibility of poison ivy exposure?
Describe the symptoms that support this diagnosis.
Determine what the patient has tried to relieve her symptoms.
What are your treatment goals for this patient?
What nonpharmacologic and pharmacologic treatment options are available for this diagnosis?
Given the information presented, develop a treatment regimen for this patient including (a) a statement of the problem, (b) a patient-specific therapeutic plan, and (c) monitoring parameters to assess efficacy and safety.
Patient Care and Monitoring: Contact Dermatitis
1. Assess the patient’s symptoms. Determine which form of contact dermatitis is present—irritant or allergic?
2. Obtain a thorough patient history. Has there been prior exposure to this agent? If so, what treatment regimens were used in the past to alleviate symptoms?
3. Obtain patient’s allergy status.
4. Develop a treatment plan appropriate for contact dermatitis.
5. Discuss testing that may need to be performed to suggest or confirm the etiologic agent (patch testing).
6. Provide patient education on contact dermatitis and treatment:
a. What is contact dermatitis and how does it develop?
b. List various types of contact dermatitis.
c. What drug therapies are available for treatment?
d. What are the possible adverse effects of drug therapy?
e. What are the symptoms that warrant physician referral.
f. Explain the importance of treatment compliance.
g. Educate on the recognition of agents that may cause contact dermatitis.
DIAPER DERMATITIS
EPIDEMIOLOGY AND ETIOLOGY
Diaper dermatitis, or more commonly known as diaper rash, is a form of irritant contact dermatitis that affects the buttocks, upper thighs, lower abdomen and genitalia of an estimated 7% to 35% of all infants.35,36 Onset of occurrence is usually between 3 weeks and 2 years of age, with the most cases reported between 9 and 12 months of age.37 The rise in the number of adults who use diapers for incontinence also increases the risk of developing diaper dermatitis.35
PATHOPHYSIOLOGY
Although many factors contribute to the etiology of diaper rash, it is most likely the result of prolonged contact of the skin with urine and feces in the diaper. If a diaper is not changed soon after urination or defecation, the protective layer of the skin can break down and make the area more susceptible to irritation and infection from the contents of the diaper.38 While most mild cases of diaper rash present as erythema, moderate to severe cases can result in the formation of papules, vesicles, and even ulceration. If these cases are not effectively treated, the likelihood of secondary fungal or bacterial infections developing is greatly increased.35
Clinical Presentation and Diagnosis of Diaper Dermatitis
Typical Symptoms
• Erythema is the most common symptom presented with a diaper rash. The rash may begin as light to medium pink with poorly defined edges, but when further developed may become dark red and raised lesions with distinct edges.
• Rashes generally appear in the folds of the skin around the diaper area, thighs, genitals, and buttocks.
• Other typical symptoms include irritation and pruritus.
Atypical symptoms
Patients presenting with the following symptoms may indicate the need for more aggressive antibiotic or antifungal therapy and should be referred to a primary care physician for further evaluation:
• Rashes not responding to typical creams and concurrent nonpharmacologic treatment
• Rashes extending beyond the diaper region (upper abdomen, back)
• Formation of papules, bullae, ulceration
• Excessive oozing
• Presence of genital discharge
• Concurrent fever
• Rashes appearing when diapers have not been used or rashes that fail to improve upon discontinuing diaper usage for extended periods of time (several days or more)
• Bleeding or open skin
Diagnosis
The diagnosis of diaper dermatitis is clinical. The presence of Candida albicans can be determined by KOH testing or culture, but is generally not necessary.
TREATMENT
Desired Outcomes and Goals
The primary goal in the treatment of diaper rash is prevention and is most often accomplished through frequent diaper changes. When a diaper rash is already present, repairing the damaged skin, relieving discomfort, and preventing secondary infections from occurring are important factors to consider when developing an effective treatment regimen.3 8
Nonpharmacologic Therapy
Most mild cases of diaper rash can be resolved with the use of nonpharmacologic therapies. Keeping the diaper area clean and dry by changing diapers as soon as practically possible is highly effective for treatment and prevention.35,36 Other nondrug options include2735 :
• Washing the area with lukewarm water and mild soap and allowing to completely dry before applying a new diaper
• Keeping diapers loose and well ventilated
• Avoiding plastic pants over diapers
• Allowing infants to take naps on an open diaper or absorbent pad to promote drying and healing
Pharmacologic Therapy
Protectants
Protectants
form an occlusive barrier between the skin and moisture from the diaper. Cream and ointment preparations are effective in providing a sufficient barrier in mild, irritant, and noninfected diaper rashes. For more severe cases, a paste is the topical agent of choice. Pastes are thicker and often contain additional ingredients (petrolatum, moisturizers) to help decrease discomfort and promote healing.37 Zinc oxide is one of the most commonly used topical protectants. In addition to forming an effective barrier against moisture, it has astringent and antiseptic properties that provide added symptom relief.35
Protectants are generally applied to the affected area after every diaper change and can be discontinued when the rash resolves. Other available protectants that can be used alone or in combination for the safe and effective treatment of diaper rash include white petrolatum, Vitamins A & D, lanolin, and topical cornstarch. Many agents contain a combination of occlusive and protective agents such as Triple Paste and Calmoseptine.
Topical Steroids
Because of the increased permeability of their skin, infants are at risk for excessive absorption and toxicity from the use of topical steroids. Although these agents are effective in decreasing inflammation and relieving pruritus, steroid use in infants for the treatment of diaper dermatitis should be limited to only the low potency preparations.39
A thin layer of hydrocortisone cream (0.25-1%) applied twice a day for no more than 2 weeks is an appropriate treatment regimen. The use of higher potency steroids or use extending beyond 2 weeks should be at the discretion of a physician only.
Antifungals
Diaper rashes lasting longer than 48 to 72 hours are at increased risk for the development of fungal infections. These complications are most frequently caused by Candida albicans and will require treatment with a topical antifungal3637 (See Fig. 65–6.)
FIGURE 65–6. Candidiasis: diaper dermatitis. Confluent erosions, marginal scaling, and “satellite pustules” in the area covered by a diaper in an infant. (From Wolff K, Johnson RA. Cutaneous fungal infections. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 721.)
Adverse events with the use of topical antifungals are generally limited to local irritation at the site of application.
Nystatin, clotrimazole, and miconazole creams or ointments applied two to four times daily with diaper changes have all shown to be effective in the treatment of candidal diaper rash. Although some of these products are available over-the-counter, parents and caregivers should be advised to initiate treatment with antifungal agents only after physician recommendation.
Antibacterials
If conventional treatment fails, unresolved diaper rash can also lead to secondary bacterial infections. Staphylococcus aureus and streptococcus are the most likely pathogens responsible for these infections and require treatment with systemic antibiotics.37,38 While • topical protectants may be used as an adjunct in treatment, suspected bacterial infections should always be referred to a physician for accurate diagnosis and the selection of an appropriate antibacterial regimen.35 Figure 65–7 shows a useful algorithm for the effective treatment of diaper dermatitis.
OUTCOME EVALUATION
Most diaper rashes can be effectively treated in less than 1 week. If symptoms do not resolve or begin to worsen, advise caregivers to seek medical attention to determine the presence of secondary fungal or bacterial infections. In addition, provide educational information on proper diaper hygiene techniques in order to prevent the development of future diaper rashes.
FIGURE 65–7. Diaper dermatitis treatment algorithm.
Patient Encounter 3
A gentleman presents to a community pharmacy with his 16-month-old daughter who recently developed a rash in her diaper area. He states that besides trying to keep the area clean and dry and changing her diapers more frequently than usual, he has tried to treat it with zinc oxide for the past 2 days. He says the rash is bright red, has persisted for 3 or 4 days and seems to be “spreading.” Although there is no blistering or oozing, he thinks the rash must be painful because his daughter cries with every diaper change.
What reported symptoms support the diagnosis of diaper rash?
Elicit additional information to aid in your assessment of this patient.
What are your treatment goals for this patient?
What nonpharmacologic and pharmacologic treatment options are available for this diagnosis?
Given the information presented, develop a treatment regimen for this patient including (a) a statement of the problem, (b) a patient-specific therapeutic plan, and (c) monitoring parameters to assess efficacy and safety.
Patient Care and Monitoring: Diaper Dermatitis
1. Assess rash symptoms. Determine the level of severity—is there a possibility of a secondary fungal or bacterial infection?
2. Identify signs and symptoms which require immediate physician referral.
3. Inquire about the patient’s history, including any similar rashes in the past.
4. Educate the caregiver on the importance of frequent diaper changes and proper hygiene.
5. Obtain patient allergy status.
6. Discuss labs that may be necessary if a secondary infection is suspected (cultures, biopsies).
7. Develop a treatment regimen for the patient, including a plan for assessing improvement of the condition.
8. Provide patient education about diaper rash etiology, treatment, and prevention:
a. What is diaper rash and how does it develop? What exacerbates diaper rash?
b. Symptoms to report to a physician (blistering, oozing, bleeding, changes in rash or no improvement in symptoms within 2-3 days).
c. Available treatment options, including proper usage instructions and potential side effects.
d. Importance of treatment compliance.
e. Prevention measures.
Self-assessment questions and answers are available at http://www.mhpharmacotherapy.com/pp.html.
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