Description

Seborrheic dermatitis, one of the most common skin disorders, is an inflammatory condition of the sebaceous, or oil, glands.

Symptoms and Signs

Seborrheic dermatitis is marked by a gradual increase in the amount of, and a change in the quality of, the sebum produced by the sebaceous glands. The inflammation occurs in areas with the greatest number of sebaceous glands. These include the scalp, eyebrows, eyelids, sides of the nose, the area behind the ears, and the middle of the chest. Affected skin is reddened and covered by yellowish, greasy-appearing scales (Figure 6-3). Itching may occur but is usually mild.

Seborrheic dermatitis can occur at any age, but is most common during infancy, when it is called cradle cap. Cradle cap usually clears without treatment by 8 to 12 months of age. Seborrheic dermatitis occurs at a higher rate in adults with disorders of the central nervous system, such as Parkinson’s disease. Patients who are recovering from stressful medical conditions, such as a myocardial infarction (heart attack); patients who have been confined to hospitals or nursing homes for long stays; and those who have immune system disorders, such as acquired immunodeficiency syndrome (AIDS), appear to be more prone to this disorder. More intense forms of seborrheic dermatitis can be seen in patients with psoriasis (see “Psoriasis” section). Mild forms are mainly cosmetic problems that can be easily treated or may disappear spontaneously.

Patient Screening

This condition has a gradual onset. The irritation becomes troublesome, and the patient or parent calls to request an appointment. Schedule the patient to be seen at the earliest convenient time or next available appointment.

Etiology

This condition is idiopathic; however, heredity may predispose an individual to the condition, and emotional stress may be a precipitating factor. Evidence suggests that this skin disorder may be perpetuated or intensified by the yeastlike organism Pityrosporum which is normally found on the skin in small numbers. Whether diet or food allergies play a role in the development of seborrheic dermatitis in infants is still unknown.

Diagnosis

In most patients, blood, urine, or allergy tests are not necessary. In the rare case of chronic seborrheic dermatitis that does not respond to treatment, a skin biopsy or more extensive testing may be performed to rule out the possibility of another disease.

Treatment

One of the more effective methods of treatment is the use of a low-strength cortisone or hydrocortisone cream applied topically to the affected area. Caution: Prolonged use of these medications should be avoided because of the possible side effects of using steroids. When the scalp is involved, causing dandruff, the frequent use of nonprescription shampoos containing tar, zinc pyrithione, selenium sulfide, sulfur, and salicylic acid also is recommended. Patients not responding to these treatments should consult a dermatologist who can prescribe stronger medications.

Treatment of cradle cap involves gentle massage of the scalp to loosen scales and improve circulation. When scales are present, shampooing daily with a mild soap is recommended. After scales disappear, shampooing may be done twice a week. Care should be taken to rinse off all soap. The child’s hair should be brushed with a soft brush after shampooing and several times during the day. When the scales do not loosen easily, mineral oil can be applied to the scalp and a warm cloth used to cover the child’s scalp for approximately an hour. The temperature of the cloth must be monitored so it does not chill down and reduce the child’s body temperature. The scalp should be shampooed and dried. If this treatment is not successful in removing the scales, the physician may prescribe a lotion or cream to be applied to the child’s scalp.

Prognosis

Most episodes will resolve with treatment. Those who do not respond positively should be referred to a dermatologist for additional drug therapy. Whether treated or not, this condition tends to recur.

Prevention

No prevention is known.

Patient Teaching

Teach the patient to properly apply the prescribed medication. For infants with cradle cap, instruct parents to shampoo the scalp daily and possibly apply gentle massage to the area with a tooth-brush.

Description

Contact dermatitis is an acute inflammation response of the skin triggered by an exogenous chemical or substance.

Symptoms and Signs

Contact dermatitis is caused either by the action of irritants on the skin’s surface or by contact with a substance that causes an allergic response. Symptoms include erythema, edema, and small vesicles that ooze, itch, burn, or sting (Figure 6-4).

Patient Screening

The patient reporting symptoms of contact dermatitis will feel the characteristic itching, burning, and stinging. These patients should be scheduled at the earliest possible time the same day they call. If this is not possible, the prudent step for patient comfort is to refer the patient to another facility.

Etiology

Many substances can induce contact dermatitis, including plants such as poison ivy, oak, or sumac. Poison ivy may be spread as an airborne irritant by burning plants. Other irritants are dyes used in soaps and facial and toilet tissue, other dyes, latex, furs, preservatives, drugs, detergents, cleaning compounds, cosmetics, chemicals, acids, and certain metals (e.g., nickel) used to make jewelry. Solar radiation and other forms of radiation, including exposure through a tanning bed, may cause the dermatitis. If an irritant remains in constant contact with the skin, the dermatitis spreads.

Contact dermatitis develops in three ways. E6-1, E6-2

First, it can develop through irritation, either chemical or mechanical, such as by latex gloves and wool fibers. If the irritant is strong, a single exposure may cause a severe inflammatory reaction.

Second, contact dermatitis may develop by sensitization. This means that the first contact with a substance causes no immediate inflammation. However, after the skin becomes sensitized, future contact or exposure results in inflammation.

Third, another interesting but uncommon mechanism for the development of this form of dermatitis is photoallergy. Some chemicals found in perfumes, soaps, suntan lotions containing para-aminobenzoic acid, or medications (e.g., tetracycline) can sensitize the skin to sunlight. The next time the individual uses the products and is exposed to sunlight, a rash develops.

Diagnosis

Diagnosis of a contact dermatitis is based on the appearance of the affected area; a medical history, including prior outbreaks and their locations; and identification of the specific irritant or allergen with a patch test.

Treatment

If a patient has come in contact with a known irritant, thoroughly cleaning the skin surface should be the first step. This should be followed by the topical application of a corticosteroid cream. An oral steroid such as methylprednisolone (Medrol) or prednisone may be prescribed for 6 to 12 days, with a decreasing dosage. Some physicians believe that 6 days is typically not a long enough treatment for many contact dermatitis conditions. Poison plant dermatitis nearly always needs at least 12 days of medication. Sometimes dermatitis rebounds after short-course steroids.

Prognosis

The prognosis varies depending on the amount of skin area involved and the likelihood that the causative agent can be removed. The response to drug therapy is usually positive when combined with removal of the offending substance.

Prevention

Identification of the offending or causative substance is primary in preventing recurrences. After the substance is identified, contact must be avoided. Should accidental contact occur, immediate intervention by removing the source and seeking drug therapy may reduce the intensity of the condition.

Patient Teaching

Encourage patients to avoid substances or situations that trigger contact dermatitis. Give information about proper methods of cleansing the skin after contact with offending substances. Instruct patients to refrain from scratching affected skin to prevent additional damage or infection from developing in the skin tissue.

Description

Atopic dermatitis (eczema) is a chronic inflammation of the skin that tends to occur in patients with a family history of allergic conditions.

Symptoms and Signs

A rash, with vesicular and exudative eruptions in children and dry, leathery vesicles in adults, develops (Figures 6-5 and 6-6). The rash occurs in a characteristic pattern on the face, neck, elbows, knees, and upper trunk of the body and is accompanied by pruritus.

Patient Screening

When the individual calls for an appointment, consider the discomfort he or she is experiencing and schedule the patient to be seen at the earliest possible time. If a prompt appointment is not possible, referral is indicated.

Etiology

Eczema is an idiopathic disease. The tendency of this condition to develop is inherited, and an allergic connection is assumed. Eczema in some infants is believed to be traceable to sensitivity to milk, orange juice, or some other foods.

A flare-up of eczema can be triggered by stress, anxiety, or conflict. Stress actually can make the condition worse. Climate, especially sudden or extreme changes in temperature, can affect or aggravate the condition. Eczema may improve in summer and flare in winter. Wool clothing or blankets in contact with the skin may also cause a flare-up of the condition. Skin barrier disruption associated with transepidermal water loss from frequent bathing and/or hand washing without moisturizing is also an important trigger factor. Eczema in infants usually subsides by the age of 2. The rash may resolve during adolescence or persist into adulthood. Eczema generally tends to improve with time.

Diagnosis

A medical history, including a family history, along with examination of the skin, confirms the diagnosis. Skin testing for specific allergies occasionally is indicated to identify underlying causes.

Treatment

The main objective in treating atopic dermatitis is reducing the frequency and severity of eruptions and relieving the pruritus. Simple atopic dermatitis may be treated with skin moisturizers, sunlight therapy, vitamin D, or calcipotriene. Unfortunately, no medications can eliminate eczema. Topical ointments and creams containing a cortisone derivative are the primary treatment for eczema. In addition, two unique new nonsteroidal antiinflammatory agents, Protopic (tacrolimus) and Elidel (pimecrolimus), are prescribed specifically to treat eczema. Local and systemic medications, such as antihistamines, tranquilizers, and other sedatives, may be prescribed to prevent or control the pruritus. Secondary bacterial or viral infections can result from scratching of the rash or lesions. A secondary bacterial infection is the most common complication. The physician usually prescribes an antibiotic to control the infection. A more serious complication of eczema can be caused by infection with certain viruses, especially the herpes simplex virus.

Prognosis

Reducing the frequency and severity of eruptions and relieving pruritus are positive outcomes. There is no cure, and eczema cannot be eliminated by medication. Medications are prescribed to control the itch-scratch cycle that aggravates the condition. Many occurrences resolve spontaneously but recur later.

Prevention

As an idiopathic disease with a tendency to be inherited and possibly with an allergic connection, eczema has no known prevention. One should attempt to prevent the secondary bacterial or viral infections that result from scratching of the rash or lesions.

Patient Teaching

Teach the patient the importance of not scratching the involved area. In young adults and older people, explain how scratching irritates the condition. Daily bathing followed by application of unscented emollients should be encouraged. Use of soap should be avoided except in body folds.

Description

Urticaria, or hives, is associated with severe itching followed by the appearance of redness and an area of swelling (wheal) in a localized area of skin (Figure 6-7).

Symptoms and Signs

Hives of various sizes can erupt as a few lesions anywhere on the skin and often are scattered over the body or mucous membrane. In gastrointestinal involvement, the patient complains of abdominal colic. When hives develop in the pharyngeal mucosa, the airway can become obstructed, causing asphyxiation. When the swelling involves deeper tissues, the condition is called angioedema and is more serious. Urticaria is common, often acute, and self-limiting, lasting a few hours. In other cases, hives continue over months or years, becoming a chronic condition. Patient complaint of itching is a significant symptom. E6-3

Patient Screening

Hives can develop into a life-threatening condition if they involve the respiratory system. Anyone experiencing respiratory difficulties should be brought into the emergency medical system for immediate assessment and intervention. Cutaneous symptoms make the individual very uncomfortable, and the patient should be seen immediately or referred to another facility for prompt assessment.

Etiology

Urticaria affects the dermis and results from an acute hypersensitivity and the release of histamine. This causes local inflammation and vasodilation of capillaries with substantial edema. Allergic reactions to food (such as shellfish, strawberries, or peanuts); drugs (such as penicillin); or insect stings (frequently from a bee) are some common causes. Infection can cause an attack of hives, as can some inhalants, sunlight, and temperature extremes. Sometimes the cause is not identified.

Diagnosis

Visual inspection of the urticaria is diagnostic. A prior episode in conjunction with a particular exposure to a known allergen is significant in the patient’s history. If the medical history is void of clues to the cause, sensitivity testing and blood tests for antibodies may help distinguish the causative agent.

Treatment

If known, the antigenic factor is removed and then avoided if possible. Antihistamines bring quick relief of symptoms. An injection of epinephrine is used in more severe cases.

In persistent cases, a course of prednisone or methylprednisolone is therapeutic. A variety of corticosteroid creams or ointments may be used also.

Prognosis

Immediate drug therapy usually resolves the allergic response, and the hives disappear. Another exposure to the same allergen will probably elicit the same response, so the triggering allergen must be avoided.

Prevention

Prevention depends on identifying the offending allergen and avoiding it.

Patient Teaching

Teach patients the importance of avoiding the causative allergen and seeking proper and prompt medical intervention in the recurrence of the condition.

Description

Psoriasis is a chronic skin condition marked by thick, flaky, red patches of various sizes, covered with characteristic white, silvery scales (Figure 6-8).

Symptoms and Signs

Psoriasis is an inflammatory chronic and recurrent skin condition with silvery scales. These scales develop into dry plaques (see Figure 6-2, C), sometimes progressing to pustules (see Figure 6-2, G). They usually do not cause discomfort but might be slightly itchy or sore. Affected skin typically appears dry, cracked, and encrusted. The most common areas in which psoriasis develops are the scalp; the outer sides of the arms and legs, especially the elbows and knees; and the trunk of the body. In addition, the palms of the hands and soles of the feet may be affected. In some patients, psoriasis spreads to the nail beds, causing the nails to thicken and crumble. Psoriasis plaques can also develop in areas of physical trauma (Koebner phenomenon). Psoriasis can occur at any age, but is more common between 10 and 30 years of age. It is noninfectious and does not affect general health.

Patient Screening

Symptoms of psoriasis are troublesome. The patient calling for an appointment for these symptoms should be scheduled for the next convenient appointment.

Etiology

The cause of psoriasis is unknown, but it seems to be genetically determined. Psoriasis may be an autoimmune disorder and is more common among the white race. Precipitating factors for the development of psoriasis include hormonal changes, such as those occurring with pregnancy, climate changes, emotional stress, and a period of generally poor health. Some drugs, including lithium, β-blockers, and NSAIDs are suspected of exacerbating psoriasis.

Diagnosis

The white, silvery scales of psoriasis are recognizable, making the condition easy to diagnose. A careful patient history, observation of the skin, or a skin biopsy may help when the scales are not evident, as with patients who bathe and scrub frequently. Scratching the lesions reveals the telltale scales.

Treatment

The goal of treatment is to reduce inflammation and to slow the rapid growth of skin cells that cause the condition. Keeping the involved skin moist and lubricated is beneficial. Treatment options include exposure to ultraviolet light to help retard cell reproduction, the use of a psoralens medication (methoxsalen) in combination with ultraviolet light, the application of topical steroid creams/ointments, the application of coal tar preparations, the application of cream containing retinoids (vitamin A derivative), the administration of low-dosage antihistamines, and oatmeal baths. Additional treatments may involve applications of creams containing synthetic vitamin D analogues (calcipotriene 0.005%). Severe cases of psoriasis may require chemotherapy with methotrexate (Trexall/Rheumatrex), acitretin (Soriatane), cyclosporine (Neoral), or the use of etretinate (Tegison), which is related to vitamin A. Caution: Pregnant women and nursing mothers should never take methotrexate, acitretin, or etretinate. Cyclosporine is in the FDA pregnancy category C. Antibiotics also may be prescribed. A new group of medications known as monoclonal antibodies and fusion proteins (biologics) have recently been approved in the treatment of psoriasis. However, long-term safety has yet to be determined with this class of medications.

Recently, a new drug called ustekinumab (Stelara) has been marketed to be more effective than etanercept (Enbrel) for treatment of psoriasis. However, both drugs are considered to be quite dangerous and may not be considered for treatment unless the psoriasis is quite severe.

Prognosis

No cure for psoriasis is known, but it is controllable. Remissions and exacerbations occur often, and the condition may require treatment for a lifetime. Advise patients to consider counseling for stress reduction because stress may cause recurrence of the disorder.

Prevention

With no identifiable etiology, no prevention is known. Keeping the skin moist and lubricated, avoiding cold, dry climates, preventing stress and anxiety, limiting alcohol intake, and not scratching and picking the skin help to prevent recurrence of the condition.

Patient Teaching

Explain the concept of exposure to ultraviolet light and methods of timing the exposure. Demonstrate application of steroid creams, coal tar preparations, and other skin creams.

Description

Rosacea, a chronic inflammatory disorder of the facial skin, causes redness, primarily in the areas where individuals blush or flush.

Symptoms and Signs

The onset of rosacea is insidious and often is mistaken for a complexion change, a sunburn, or even acne. The redness becomes more noticeable and does not go away. The skin then may begin exhibiting dryness and pimples that may become inflamed or filled with pus. In addition, small blood vessels of the cheeks and face enlarge and show through the skin as red lines even after the redness diminishes (Figure 6-9 and Figure 6-10). Small knobby bumps occasionally appear on the nose, causing it to look swollen, mostly in the male with rosacea.

Ocular rosacea, an inflammatory eye condition, is a less common form of rosacea. The blood vessels in the sclera become inflamed and the eyelids appear to be reddened and swollen often with small inflamed bumps and eyelashes that fall out. The individual may experience burning or a gritty feeling in the eyes. The eyes have a bloodshot appearance.

Etiology

The etiology of rosacea, a chronic and often cyclic condition, is unknown. A possible correlation with the frequency of the individual’s blushing or facial flushing has been suggested. Those with lighter complexions appear to have a greater incidence of the disorder, and rosacea possibly may be inherited. Rosacea is not considered to be infectious or contagious and is not spread by skin contact. The etiology of ocular rosacea also is unknown.

Diagnosis

Rosacea is diagnosed from the history of facial blushing and flushing. Although rosacea often has many of the same symptoms as acne, the individual experiencing episodes of rosacea does not have the blackheads or whiteheads (comedones) typical of acne. A dermatologist should be consulted for a definite diagnosis.

Ocular rosacea is diagnosed by history of chronically bloodshot eyes and examination of the eyes that usually reveals inflammation and debris on the eyelids’ margins.

Treatment

Rosacea has no cure, but symptoms can be controlled through medical treatment with Finacea 15% (azelaic acid), metronidazole cream 1%, sodium sulfacetamide, and topical antibiotics, (erythromycin, clindamycin) and change of lifestyle. The patient is urged to identify situations that cause him or her to blush or experience facial flushing and attempt to avoid these triggers. These events may be different for various rosacea sufferers, so the patient would be wise to avoid sunlight, hard exercise, extreme heat or cold, stress, spicy foods, hot drinks, and alcohol. Sun exposure, hot weather, cold weather, and wind all have been identified as triggers, as have abrupt changes of season and weather extremes. The physician may prescribe medications to control the redness. Antibiotics (minocycline, doxycycline, or tetracycline) sometimes are prescribed. For stubborn cases, redness can also be treated with laser surgery. Mild cleansers should be used, and moisturizers that do not contain alcohol or drying agents should be applied routinely. Sunscreens help. Consistent treatment is necessary to prevent flare-ups.

Treatment of ocular rosacea is similar to treatment of facial rosacea and includes daily cleansing of eyelids with a form of diluted nontearing shampoo. If the individual is not allergic, antibiotics (minocycline, doxycycline, or tetracycline) sometimes are prescribed.

Prognosis

As previously mentioned, rosacea has no cure, but the patient may be able to control symptoms with medical treatment and modification of lifestyle. Similar to facial rosacea, ocular rosacea has no cure.

Prevention

The etiology is unknown, so prevention is not possible. Identifying situations with the potential to cause blushing or facial flushing and attempting to avoid these triggers are helpful. Avoiding sunlight, hard exercise, extreme heat or cold, stress, spicy foods, hot drinks, and alcohol also helps. The patient also is urged to avoid triggers such as sun exposure, hot weather, cold weather, wind, and abrupt changes of the seasons and weather extremes.

Patient Teaching

Work with patients to identify causative factors and discuss ways to avoid these factors. Assist them in locating and contacting support groups for this disorder.

Description

Acne vulgaris is an inflammatory disease of the sebaceous glands and hair follicles. Papules, pustules, and comedones are usually present (Figure 6-11).

Symptoms and Signs

Acne vulgaris is marked by the appearance of papules, pustules, and comedones (see Figure 6-2, B, G, and L). Deeper, boil-like lesions called nodules sometimes can occur. Scars may develop if the chronic irritation and inflammation continue for a long period. Acne is found most often on the face but also can occur on the neck, shoulders, chest, and back (Figure 6-12). Acne can appear at any age, but is more common in adolescents. In girls, it is usually at its worst between the ages of 14 and 17 years. In boys, it reaches its peak in the late teens.

Patient Screening

Many calls requesting appointments for treatment of acne type of conditions will be for teenagers. Acne is not a medical emergency, but an individual experiencing its symptoms may be feeling emotional stress. Therefore the physician should schedule these patients for the next available appointment.

Etiology

The cause of acne vulgaris is unknown. Research on the cause, however, links it to hormonal changes of adolescence that affect the activity of the sebaceous glands. Hereditary tendencies also are known to be predisposing factors. Precipitating factors may include food allergies, endocrine disorders, psychological factors, fatigue, and the use of steroid drugs.

Sebum, an oily substance produced by the sebaceous glands, reaches the skin surface through the hair follicle. Overproduction of the oil seems to stimulate the follicle walls, causing a faster shedding of skin cells. This causes the cells and sebum to stick together and to form a plug, which promotes the growth of bacteria in the follicles. This is the process by which pimples and nodules form.

Diagnosis

Examination of the characteristic lesions and patient history confirm the diagnosis.

Treatment

Therapy may include the use of topical or systemic antibiotics or both. Topically applied keratolytic agents may prove appropriate for many cases of acne. Topical application of medications chemically related to vitamin A (e.g., tretinoin [Retin-A], adapalene) reduces the skin’s natural oils and promotes drying and peeling of the acne lesions. Benzoyl peroxide gels are also effective. Antibiotics are prescribed to kill bacteria residing on the skin or in the lesions. Long-term antibiotic use for acne treatment, however, may have side effects. Often combination therapy including benzoyl peroxide, topical antibiotics, and retinoids is the most effective.

For severe acne, isotretinoin (Accutane) may be indicated. Isotretinoin helps to reduce the amount of sebum the body manufactures. Low-dose estrogen is prescribed to balance hormone levels. Optimal results usually are obtained by incorporating medications. Caution must be taken in the use of isotretinoin because it may produce serious psychological side effects, including depression, psychosis, and even suicide. Pregnant or nursing mothers should never take isotretinoin. E6-4 Isotretinoin is a vitamin A derivative that is administered under an FDA program called IPLEDGE. Providers (physicians, nurse practitioners), patients, and pharmacists must participate in the IPLEDGE program. E6-5

Prognosis

The prognosis varies depending on the extent of the acne and the individual’s compliance with the medication regimen, including all topical and ingested medications prescribed.

Prevention

The etiology is unknown, so no prevention is known.

Patient Teaching

Give patients information about acne and its care. Teach patients the methods of applying dermal medications. Encourage patients to report any side effects resulting from oral medications. Emphasize the importance of not squeezing any pimples or pustules. In addition, emphasize the importance of good hand washing after touching involved skin areas.

Description

Herpes zoster, or shingles, is an acute inflammatory dermatomal eruption of extremely painful vesicles.

Stay updated, free articles. Join our Telegram channel

Join