Diaper Dermatitis and Prickly Heat o May continue to use skin protectants prophylactically after

Diaper Dermatitis resolution to prevent recurrence of diaper dermatitis

o Also known as diaper rash
o Occurs most commonly in infants
o Often caused by a combination of factors:
Occlusion by diaper
Moisture due to incontinence
Urine and fecal bacteria
GI enzymes and bile salts
Skin pH changes
Mechanical friction, skin chaffing and irritation
Diaper Dermatitis Presentation
o Irritated, erythematous, shiny or wet appearing lesions
Perineum area, buttocks, upper thighs and/or lower
abdomen
o Sever cases can progress to maceration, skin erosion,
vesicles or pustules and secondary infection
o Irritated, erythematous, shiny or wet appearing lesions
Perineum area, buttocks, upper thighs and/or lower
abdomen
Appearance may be similar to skin infection or
allergic contact dermatitis, so its important to assess
other clinical features
o Rash can appear quickly on previously normal looking skin
Diaper Dermatitis Treatment
o Goals: relieve symptoms, eliminate the rash, minimize risk
of infection, prevent recurrence of rash
o Uncomplicated and mild to moderate cases may be self
treated
o Non-pharmacologic:
Frequent diaper changes
Gentle wiping with mild infant wipes
Rinse skin with water and gently dry or allow to air
dry
Utilize disposable diapers with moisture wicking
materials
Minimize or eliminate use of washable cloth diapers
o Pharmacologic:
Skin protectants primary pharmacologic treatment
Lubricate the skin
Form a protective barrier along the skin
Very good safety profile
o NOT APPROPRIATE for diaper dermatitis:
Topical antibiotics
Topical antifungals
Topical analgesics
Topical steroids
FDA-Approved Skin Protectants
o Allantoin, Calamine, Cocoa butter, Cod liver oil, Colloidal
oatmeal, Dimethicone, Glycerin, Hard fat, Kaolin, Lanolin,
Mineral oil, Petrolatum, Topical cornstarch, White
petrolatum, Zinc acetate, Zinc carbonate, Zinc oxide
Counseling Points for Skin Protectants
o Use in combination with non-pharmacologic measures
o Apply a liberal amount of skin protectant over the entire
diaper area with each diaper change
o Several types of products are available including
ointments, creams, pastes, powders
Avoid use of loose powder products near infants face
o Should begin to see improvement within 24 hours
Prickly Heat Dermatitis
o Also known as heat rash or miliaria
o May occur in patients of any age
o Caused by blocked sweat glands
Sweat cannot be released from the pores
Leads to dilation/rupture of the pores and
inflammation of the dermis
o Most commonly occurs in hot, humid conditions, during
vigorous work or exercise and/or in other conditions that
cause perfuse sweating
May also occur due to tight-fitting or occlusive
clothing
Prickly Heat Dermatitis Presentation
o Raised, erythematous, pinpoint-sized papules with itching,
stinging or burning
o Common sites:
Axillae
Chest
Upper back
Back of neck
Abdomen
Inguinal area
Prickly Heat Treatment
o Goals: remove causes of the rash, eliminate rash, relieve
symptoms
o Non-pharmacologic: remove the cause
Wear loose, lightweight clothing
Avoid occlusion of skin
Move to a cooler environment
o Pharmacologic: used for symptom relief
Water-washable skin emollients/lotions
Colloidal oatmeal products
Good option for children/infants
Topical steroids (hydrocortisone)
May be used in adults only if 10% body surface
is affected
Contraindicated for infants
Prickly Heat Product Selection and Counseling Points
o Goal is to relieve symptoms while not blocking skin
exposure to the air
o Recommend creams or lotion products, not ointments
Product should be water-washable
Apply a thin layer only
Avoid over application
o Powder products absorb moisture and dry the skin
May be used to prevent prickly heat
Not recommended for active prickly heat
o Expect improvement within 24 hours
Exclusions to Self-treatment: Diaper Dermatitis and Prickly
Heat
o > 7 days duration or no improvement after 7 days of
treatment
o Diaper dermatitis type rash occurring outside of diaper area
o Broken skin, oozing, bleeding, vesicle formation and/or
presence of pus
o Evidence or suspicion of infection
o Chronic or frequent recurrence
o Immunosuppressive conditions
 o Signs of heatstroke
Patient Case: L.B. is an 8 month old female patient with a
bright red patchy rash covering her buttocks that appeared
rather suddenly according to her mother. There is no
maceration, vesicles or oozing.
o What is the most likely cause of L.B.s presentation?
o Can this condition be self treated?
o What would you recommend for L.B.?
o What are some important counseling points to tell L.B.s
mother?
Pinworm Infection
o Common helminthic infection caused by Enterobius
vermicularis
Intestinal parasite
Small, thread-like, white worm (~1 cm in length)
o Transmitted by direct anal-oral transfer of eggs
Female pinworms migrate out of the colon and lay
eggs in the perianal area
Infection (or re-infection) occurs when the eggs are
ingested
o Most common in children
Pinworm Lifecycle
Presentation
o Intense itching in the perianal or perineal area, most often
during the night
Some patients may be asymptomatic
Major infestations may be associated with more severe
symptoms such as abdominal pain, restlessness,
insomnia, intractable itching, diarrhea, anorexia
o Potential complications include:
Secondary bacterial infection
Urinary or genital tract infection
Appendicitis
Diagnosis
o If nocturnal perianal itching is present, the infection can be
confirmed by:
o Nocturnal visualization of worms around perianal area or:
Tape test and microscopic examination
Treatment
o Treatment must involve both non-pharmacologic measures
and pharmacologic therapy
o Goals: eradicate pinworms, relieve symptoms, prevent
reinfection and transmission of infection
Treatment Non-pharmacologic
o Avoid scratching
o Promote good personal hygiene
Bathe daily in the morning, rather than at night
Wash hands regularly
Keep fingernails clean and trimmed
o Change and wash bed sheets, clothing, towels daily in hot
water and dry in a hot dryer during treatment and for
several days afterward
o Mop, clean and vacuum daily during treatment and for
several days afterward
Treatment Pharmacologic
o Pyrantel pamoate: nonprescription product
o Albendazole: prescription-only product
o Mebendazole: no longer available in the U.S.
Pyrantel Pamoate
o 90-100% effective in eliminating pinworm infection
Not effective on eggs
o Causes paralysis of the worm and excretion of the worm
via the feces
o Dose: 11 mg/kg (pyrantel base) PO x1 dose
May repeat dose x1 after two weeks if needed after
consultation with physician
o Seek advice from physician before recommending
treatment to patients <2 years old or < 25 pounds
Side effects:
Most common: nausea, vomiting, diarrhea, abdominal
pain
Less common: headache, dizziness, insomnia, rash
Rare/serious: AST elevation, ototoxicity, paresthesia
o May take with or without food
o Pregnancy category C
o Available in multiple dosage forms: suspension, tablet,
chewable tablet
Albendazole
o Available by prescription only
Treatment of pinworm is an off-label use
o Dose:
Adults and children >2 years old: 400 mg PO x1,
repeat x1 in 2 weeks
Counseling Points
o Encourage strict hygiene measures
o Treatment should include both non-pharmacologic and
pharmacologic measures
o Entire family/household should receive treatment
o Symptoms should resolve within two weeks
o Physician should be contacted for non-resolution of
symptoms after two weeks
Exclusions to Self-treatment
o Children < 2 years old or < 25 pounds unless self-treatment
recommended by physician
o Pregnant or breast feeding
o Liver dysfunction
o Symptoms inconsistent with pinworm infection or
helminthic infection other than pinworm suspected
o Need for repeated dose after first treatment
 Patient Case: A.V. is a 6 year old female child who attends 1 st
grade. She weighs 22 kg and has no significant past medical
history. Her father reports that the child had been complaining
of being awakened by perianal itching at night. On the advice of
the pediatrician, a visual exam was performed one night and
small white worms were noted around the childs anal area.
o What non-pharmacologic and pharmacologic therapies
should be recommended for A.V.?
o Within what timeframe would symptoms be expected to
resolve?
o What are some other important counseling points?
Warts
o Very common
o Caused by human papillomaviruses (HPV)
o Affect the epidermis
Some types of warts may affect mucous membranes
o Long incubation period (up to 8 months)
o Transmitted by person-to-person contact, contact with
contaminated surfaces, or autoinoculation
Presentation
o
Presentation
o Warts vs. other dermatologic problems:
Corns/calluses: if the outer keratinous layer is
removed, a wart will exhibit pinpoint bleeding, but a
corn or callus wont (this should be done by a
healthcare provider only)
Malignancies: a malignant growth will likely be
painful, irregular and discolored, will bleed and will
grow rapidly
Risk Factors
o Prior history of warts
o Immunosuppression
o Use of swimming pools and public bathing facilities
o Walking barefoot
o Biting of fingernails
o Meat handling
Treatment
o Many warts will resolve on their own without any
treatment
23% resolve within 2 months
30% resolve within 3 months
More than two-thirds resolve within 2 years
o Wait-and-see approach may increase the risk of
transmission or autoinoculation
o Goals: remove wart, reduce risk of transmission, prevent
recurrence of warts
Treatment Non-pharmacologic
o Avoid cutting, shaving or picking at warts
o Wash hands after touching warts
o Keep warts covered
o Avoid walking barefoot
o Keep feet clean and dry
o Dry warts with a separate towel
o Avoid sharing personal items and footwear with others
Treatment Pharmacologic/Alternative
o Pharmacologic
Salicylic acid
Cryotherapy
o Alternative therapies
Complementary therapies
Duct tape
Salicylic Acid
o Topical keratolytic product that works by causing
destruction of hyperkeratotic cells
o May be used on common or plantar warts
o Easy to use, accessible, affordable and effective product
o Improvement often noted after a few weeks of regular use
o Adverse effects: local irritation, risk of systemic toxicity
(rare)
Salicylic Acid Product Selection
o Several formulations (and strengths) available:
Salicylic acid in plaster vehicle (12-40%)
Salicylic acid in collodion vehicle (17%)
Salicylic acid in karaya gum glycol vehicle (15%)
o Higher concentration products (up to 40%) may be used on
plantar warts
o Lower concentration products are recommended for
common warts on the hands (17%)
o Select product based on patient preference and ease of use
Salicylic Acid General Directions for Wart Treatment
o All products may be used for up to 12 weeks for wart
treatment
o See individual product packaging for exact, product
specific instructions
Cryotherapy
o Freezing of tissue leads to a local inflammatory response
and destruction of the infected cells
Intracellular ice crystals form
A blister will form underneath the wart and the wart
will eventually fall off
o Available therapies include:
Liquid nitrogen must be administered by a
healthcare provider
Dimethyl ether/propane products available without a
prescription
o Self-treatment may be repeated every 2-3 weeks until:
Resolution of the wart or Maximum number of total
treatments reached (typically 3-4 total treatments for
most products)
o Do not exceed 3 months duration of treatment
o Adverse effects:
Pain
Damage to surrounding healthy skin,
Blistering/scarring
Change in skin pigmentation
 Tendon or nerve damage o 1. Androgenetic alopecia
Cryotherapy General Directions for Use Most common
o Wash hands before and after use Gradual loss of hair due to hereditary or hormonal
o Soak the wart in warm water causes
o Remove keratinous surface of the wart with a file Includes both male and female pattern hair loss
o Apply the product directly to the wart, taking care to avoid Alopecia: loss or absence of hair
applying to the surrounding healthy tissue o 2. Alopecia areata
o Discard applicator after use Sudden, patchy hair loss
o There are multiple products available see individual Possible autoimmune cause
product packaging for directions specific to that product o 3. Anagen effluvium
Alternative Therapies for Warts Sudden loss of up to 90% of hair
o Folk remedies Commonly caused by cancer chemotherapy treatments
o Vitamin A Effluvium shedding of hair
o Zinc o 4. Telogen effluvium
o Garlic May be acute or chronic
o Essential oils Diffuse shedding or thinning of the hair
o Duct tape Frequently associated with a precipitating event or
Exclusions to Self-treatment of Warts factor
o Children < 4 years of age Stress, metabolic or hormonal imbalances,
o Pregnant or breastfeeding medications, severe illness, injury, trauma
o Poor circulation or chronic conditions that can lead to poor Reversible with removal of precipitating factor
peripheral circulation and/or sensation o 5. Trichotillomania
o Inability to safely use nonprescription products Compulsive hair pulling disorder
o Multiple or mosaic warts Most common in children
o Painful or large warts o 6. Hair loss secondary to tinea capitis
o Warts located any place other than the hands or feet Superficial fungal infection
o Immunosuppressed patient May cause loss of hair if untreated
Patient Case: L.A. is a 31 year old female who presents with a o 7. Hair loss secondary to cosmetic damage
small, rough, skin-colored lesion on her left hand. She says she o 8. Scarring alopecia
first noticed it about two months ago and its gotten a little bit Permanent hair loss secondary to hair follicle
bigger. She reports no pain, bleeding, redness or discharge from destruction
the lesion. She initially thought it was a callus, but now she Causes include: cosmetic practices, traction, scaly
isnt sure. She asks what you think it is and if she should see her dermatoses, autoimmune conditions
doctor or if she can treat it herself. Androgenetic Alopecia Pattern Hair Loss
o What type of lesion does L.A. most likely have? o Male Pattern
o Is this something that can be self treated? Receding frontal and occipital hairlines
o What non-pharmacologic measures should L.A. Thinning of hair at the vertex
implement? o Female Pattern
o What are the available pharmacologic options? Diffuse thinning of hair over the crown and mid-
o How would you counsel L.A. about the use of the selected frontal regions
pharmacologic agent? Assessment of Hair Loss
o Hair pull test
Hair loss Grasp 40-60 hairs between thumb and forefinger and
o Common dermatologic problem firmly pull down the length of the hairs
Up to 50% of men and women may be affected at Positive if more than 10% of hairs come loose
some point throughout their lives Positive test: alopecia areata, anagen effluvium,
o Can have a significant emotional and psychological impact telogen effluvium
o Many different etiologies Negative test: androgenetic alopecia
Phases of Hair Growth o Norwood, Ludwig, Savin and/or Sinclair scales
Pictorial scales that may be used to classify or
evaluate the progression or extent of hair loss in
androgenetic alopecia
o Scalp biopsy
May be done to further assess or identify cause of hair
loss
Treatment of Hair Loss
o Goals: improve appearance, reduce distress associated with
hair loss
o Non-pharmacologic measures:
Types of Hair Loss Utilize camouflaging products
Wigs, hair sprays/gels, colorants
 Avoid practices that may further damage the hair Increased hair loss may be noticed at first when
Surgical transplantation of hair follicles initiating treatment with topical minoxidil
o Pharmacologic Treatment May take up to 4 months to see new hair growth
Androgenetic hair loss is the only type that may be New hair growth may be less likely in patients
self treated who have had thinning of hair for a prolonged
Topical minoxidil is the only available over-the- period of time
counter treatment for hair loss If effective, treatment should be continued
Minoxidil is also available as an oral medication indefinitely to maintain effect
for the treatment of If new hair growth is not seen within 4-6 months
hypertension of appropriate use, discontinuation of minoxidil
Oral form is NOT used for hair loss treatment should be considered
Topical Minoxidil (Rogaine) Other Therapies
o Approved for use in both men and women for androgenetic o Finasteride (Propecia)
alopecia Available by prescription only
o Stimulates hair follicle growth by increasing cutaneous Approved for alopecia treatment in men only
blood flow to the scalp Dosing: 1 mg PO once daily
o Several strengths and dosage forms available: May be considered in men who have failed topical
2%: topical solution minoxidil
5%: topical foam, topical solution Has been studied in combination with 2% topical
Minoxidil General Directions for Use minoxidil solution in male patients
o Topical solution: o Complementary therapy
Apply 1 mL of solution to affected areas of the scalp Dietary and herbal supplements
BID Shampoos and topical solutions
Allow 2-4 hours for the solution to fully dry and Exclusions to Self-treatment
penetrate the scalp o <18 years old
Wash hands after use o Any suspected hair loss condition other than male or
o Topical foam: female pattern hair loss
Wash hands in cold water and dry thoroughly o Positive hair pull test
Dispense one half capful of foam onto the fingertips o Sudden hair loss
Part the hair within the thinning area and apply the o Hair loss associated with changes in nails
foam to the scalp o Loss of eyebrows or eyelashes
For men: apply BID o Pregnant, breastfeeding or post-partum
For women: apply once daily o Recent discontinuation of oral contraception
Wash hands after use o No family history of hair loss
Minoxidil Patient Case: C.R. is a 40 year old male patient who presents
o Common side effects: to the pharmacy complaining of progressive, gradual hair loss
Itching, irritation, dryness, contact dermatitis at the from his frontal hairline and also a thinning of the hair on the
application site top of his head over the past 2 years. His PMH includes
Excessive hair growth diverticulosis and gout. His only current medication is
o Rare side effects: allopurinol 100 mg PO daily. He saw a commercial for an over-
Acne the-counter hair loss foam and asks for your recommendation.
Hair loss o What type of hair loss is C.R. presenting with?
Inflammation of hair roots o Is this a self-treatable type of hair loss?
Facial swelling o What would you recommend to C.R.?
Allergic dermatitis o What counseling points should you mention to C.R.?
Systemic effects
o Drug interactions:
None significant
Avoid application of other topical products to the
scalp, as the absorption of minoxidil may be increased
o Warnings:
Not to be used in children <18 years old
Avoid use on damaged, irritated, sunburned or
inflamed scalp
Do not use more frequently than recommended
May cause increased risk of cardiotoxicity in patients
with heart disease
Topical solution is flammable
Pregnancy category C
o Counseling points: