Dermatology
Sun burn
Exclusions:
• Severe burns
Appearance/Features:
• Erythema 3-4 hours
• Peak 12-24 hours
Considerations:
• Avoid topical anesthetics can sensitive to contact dermatitis
Prevention:
• Sunscreen the higher the SPF the better
• Apply 15mins prior to sun exposure & every 2 hours or sooner during exposure
Age:
• Can happen at any age
Complications:
• Long term: Cancer and premature aging
• Short term: Heat related illnesses such as dehydration
• Short term: Exacerbate chronic illness such as SLE, Herpes, Eczema
Pharm:
• Analgesics for pain and inflammation
o NSAIDS
Non-Pharm:
• Cool compress
• Aloe to improve symptom intensity but doesn’t shorten duration
Wounds
Exclusions:
• Full thickness
• Burn > 2% BSA
• Burn near eyes, ears, face, hands, feet, or perineum “Between genitals”
• Chemical, electrical, or inhalation burns
Appearance/Features:
• N/A
Considerations:
• Risk factors for healing are:
o Poor vascular blood flow
 Diabetes
 Hypotension
 Anemia
o
o
o
o
 Heart failure
Bacterial infection
Bad nutrition
Older age
Medications
 Corticosteroids
 Chemotherapy
 Immunosuppressants
Goals:
• Relieve symptoms
• Promote healing
• Minimize scarring
Age:
• N/A
Complication:
• N/A
Pharm:
• Skin protectants:
o Examples:
 Allantoin
 Cocoa Butter
 Petrolatum
 Shark liver oil
o Used to prevent friction and dryness
o Apply as needed but if no results after 7 days seek medical attention
• Topical Anesthetics:
o Examples:
 Benzocaine
 Lidocaine
 Dibucaine
 Tetracaine
 Butamben
 Pramoxine
o Block pain receptors for 15-45mins
o Apply no more than 3-4 times per day
o Do not use on more than 1-2% of BSA
o Higher concentration may be used on intact skin
• Topical Antiseptics:
o Examples:
 Hydrogen peroxide
 Ethyl alcohol
 Isopropyl alcohol
 Iodine solution
 Povidone/Iodine
o Limit risk of infection without causing tissue injury
o Best for intact tissue
o May dehydrate skin
o Not for chronic use
• Topical Antibiotics:
o Examples:
 Polymyxin B sulfate
 Bacitracin zinc
 Neomycin
o Prevent infections in burns and wounds
o Can be applied 1-3 times per day
o Not sufficient treatment for contaminated wounds
o Seek medical attention after 7 days of no improvement
o Not for prolonged use may cause bacterial resistance
Non-Pharm:
• Irrigation of wound
• Cool compress burn
• Non-Adherent hypoallergenic
• Remove source of injury
Dry Skin
Considerations:
• Usually, a symptom of a secondary issue such as hypothyroidism, asthma, and allergies
• May be accompanied with Pruritis “itching”
o Cool compress and use hydrocortisone for one week
Prevention:
• Short warm showers
• Gentle soaps
• Moisturize
o Petroleum jelly, mineral oil, etc.
• Wear cotton
• Drink water
• Use sunscreen and humidifier
Atopic Dermatitis Eczema
Exclusions:
• Moderate to severe with intense pruritis
• Large area of body involved
• Less than a year old
• Skin infection
• Involvement in face or intertriginous areas
• No improvement of rash with 3 days of self-care
Appearance/Features:
• Redness
• Itching
• Swelling
• Skin lesion
• Pattern:
o Kids:
 Mostly on face, neck, and extensors
o Adults:
 Current or previous flexural lesions, sparing of groin and axillary regions
Considerations:
• May use antibiotics for secondary infection
• May use systemic corticosteroids for severe resistance disease
o Short term only potential for rebound
Prevention:
• Maintain skin hydration
• Limit exposure to triggers
• Reduce pruritis
• Prevent secondary infections
Age:
• Most common in kids but may outgrow it by adolescence
Complication:
Pharm:
• First line:
o Topical corticosteroids:
 Hydrocortisone 0.5-1% for ages 2 and above
 1-2 times a day
 Continue to use 3 days after rash has cleared
 Max use 1 month for OTC
 ADR:
• Local: skin thinning, atrophy, worsening acne, petechiae, and
telangiectasia
• Systemic: reduced linear growth in children and reduced bone
density in adults
o Drug selection based on age (lower potency) and location of lesion (lower
potency near face, groin, axillae)
• Second line: Prescription (Rx)
o Topical Calcineurin inhibitors
 Pimecrolimus (Elidel) 1% or Tacrolimus (Protopic) 0.03-0.1%
• Apply 2 times per day
• Blocks T cell activation and Cytokine release
 Must be over 2 years old
 May cause malignancy
 Effectiveness similar to topical corticosteroids
o Crisaborole (Eucrisa)
 PDE-4 inhibitor
 Mild-moderate above the age of 2
 Apply two times a day
 ADR: local burning and stinging
o Dupilumab (Dupixent)
 IL-4/IL-3 inhibitor
 Moderate-severe in adults only
 600mg initial dose followed by 300mg every other week
• Available in 300mg/2ml single use syringe
 Don’t use with live vaccines
• Third line
o May use UV phototherapy
Non-Pharm:
• Emollients
o Apply 2 times per day after bathes
• Bathing in warm water
o Infants may bathe every 2-3 days
• Cotton gloves and socks at bedtime
Etiology:
• Genetics
• Environment
• Impaired immune system
Contact dermatitis
Exclusions:
• Difficulty breathing and fever
• No improvement in rash after self-care
• Rash increase in size
• ADR from current treatment
Appearance/Features:
• Irritant:
o Caused by direct injury to skin
o Onset in minutes to hours
o Resolution is fast upon removal of aggravating agent
• Allergic:
o Delayed hypersensitivity reaction
o First exposure doesn’t provoke reaction, but re-exposure causes delayed
response
 Hours to days
o Caused by things like poison ivy, metals, smoke, local anesthetics, latex.
Goals:
• Relieve symptoms
• Reduce secondary infections
Pharm:
• Astringents:
o Examples:
 Calamine lotion, witch hazel, burrows solution
o Topical vasoconstrictor
o Decreases itching and oozing
o ADR: Dry skin
o Apply as a compress 15-30mins 2-4 times per day for a max of 7 days
• Topical corticosteroids
o Reduces inflammation pain and itching
o Works in similar fashion as in atopic dermatitis
o Apply 2-4 times daily for 7 days max
• 1st generation antihistamines (systemic)
o Examples:
 Diphenhydramine & Hydroxyzine
o Decrease pruritis by blocking histamine reaction
o ADR: Sedation and anticholinergic
o For ages 2 and older
o Topical antihistamines not as effective
Non-Pharm:
• Colloidal oatmeal bath
• Cool soap less showers
• Cool, moist compress for 30 minutes 3 times a day
• Emollients after shower
Diaper Dermatitis
Exclusions:
o Rash not responding to treatment
o Rash extending beyond diaper area
o Papules or ulceration formation
o Oozing
o Genital discharge
o Fever
o Bleeding
Appearance/Features:
• Pink is mild
• Red is severe
Considerations:
• Form of irritant contact dermatitis
Goals:
• Prevent rash
• Promote skin repair
• Relieve discomfort
• Prevent secondary infection
Age:
• Common in 3 months to 2 years old
• Peak at 9-12 months
• Can affect adults
Pharm:
• First line:
o Protectants
 Example:
• Zinc Oxide
 Form barrier between skin and diaper contents
 Mild-moderate use a cream or ointment
 Severe use a paste
 Apply with each diaper change
o Topical corticosteroids
 Example:
• Hydrocortisone cream 0.25-1%
 Limit use to low potency for no more than 2 weeks to avoid systemic
absorption
 Not recommended for self-treatment
o Topical antifungal
 Example:
• Clotrimazole
 Diaper rash that lasts for longer than 48-72 hours increases risk of fungal
infection
 Apply 2-4 times daily with diaper change
 Not recommended for self-treatment
o Systemic antibacterial
 Most common bacteria are streptococci and staphylococcus
 Not recommended for self-treatment
Non-Pharm:
• Wash with warm water and mild soap
• Keep diaper loose and ventilated
• Avoid plastic pants
• Allow naps in open diaper
Prickly Heat AKA Miliaria
Appearance/Features:
o Miliaria Crystallina: Small thin-walled vesicles (Dew Drops) with no inflammation
o Miliaria Rubia: Cluster of small papules with localized inflammation
Etiology:
o Excessive buildup of sweat below eccrine sweat ducts caused by keratin obstruction at
the stratum corneum
Considerations:
o It is self-limiting once sweating is avoided
Goals:
o Alleviate symptoms
o Promote healing of lesions
o Prevent secondary infections
Non-Pharm:
o Cool environment
o Light clothing
o Cool bathes
o Sodium bicarbonate 1 TSP- 1Cup topically
o Avoid Talcum powder
Seborrheic dermatitis and scalp disorders
Exclusions:
Appearance/Features:
o Dandruff: Hyperproliferative, accelerated epidermal turnover, limited to crown of head,
skin flaking and itching most common symptom
o Seborrheic: Inflammation, epidermal cell turnover more rapid, extends beyond scalp,
skin flaking and itching most common symptom
o Oily
o Relapsing
o No oozing
o Worse in dry conditions
Considerations:
o Associated with:
o Hormone levels
o Fungus
o Nutritional defects
o Neurogenic factors
o HIV/AIDS
Goals:
o Reduce epidermal turnover
o Minimize scaling, pruritus, and erythema
o Can’t be cured just controlled
Age:
o Infants less than 3 months (cradle cap)
o Adults 30-60
o More common in men
Pharm:
o Keratolytic agents (Scaling on scalp and no inflammation)
o Examples:
 Pyrithione zinc may also be antifungal
 Coal tar
 Salicylic acid
 Sulfur
o Use 2-3 times per week
o Apply for at least 5 minutes prior to rinsing
o Antifungal agents (SD of scalp and face)
o Examples:
 Ketoconazole 1-2% (Nizoral)
 Selenium sulfide 1-2.5% (Selsun blue)
 Cicloprox 1-1.5%
o Apply 2-3 times per week for scalp
o Apply 2 times a day for non-scalp
o Often used in combo with corticosteroids
o Anti-inflammatory Agents
o Corticosteroid Examples (SD of scalp and face):
 Fluocinolone 0.01% shampoo (Synalar) Twice a week
 Betamethasone valerate lotion (Beta-Val) Once or twice per week
 Desonide cream (Desowen) Once or twice daily
o Calcineurin Inhibitor Examples (SD of face):
 Tacrolimus ointment (Protopic)
 Pimecrolimus cream (Elidel)
 One week for benefits to show
Non-Pharm:
o Tea tree oil shampoo (Melaleuca oil)
o Available in 5% shampoo
o Well tolerated and effective
Alopecia
Appearance/Feature:
o Exogen phase > anagen phase
o Hair enters telogen phase prematurely
o Trauma to follicles
Pharm:
o Minoxidil (Rogaine)
o For male and female
o Prolongs anagen phase
o Dosing: 1ml solution to scalp BID or ½ capful foam to scalp BID
 2-5% for men
 2% for women
 5% foam for women once a day but solution not approved
o Indefinite treatment
o ADR: skin irritation, contact dermatitis, increased facial hair
o Should use product for at least four months to see results and must be applied to
APEX of scalp
o Finasteride (Propecia)
o Only for males
o 5A reductase inhibitor
 Inhibits DHT formation
o Dosing: 1mg tab PO daily
o Indefinite treatment
o ADR: Low libido, erectile dysfunction, gynecomastia, myopathy
o Should use product for 3 months to see results, PSA levels low in elderly,
prostate screenings still required
o NON-FDA approved
o Spironolactone
 For females with hyperandrogenic condition
 Dosing: 100-200mg PO daily
 Slows hair loss by blocking aldosterone receptors
Insect bites
Exclusions:
Appearance/Feature:
o Mosquito
o Warm climates
o Welt and itching
o Injects anticoagulant
o Can be vector for West Nile and Zika Virus
o Fleas
o Warm and humid climates
o Redness and itching
o Attracted to body heat
o Clustered bites on legs and ankles
o Can be vector for typhoid
o Mite
o Burrow under skin and lay eggs which causes scabies a contagious infection
o Inflammation, intense itching, and immune response
o Bites are between fingers, external male genitals, buttocks, and flexor of wrist
o Bedbugs
o Bite at night
o Mild irritation to dermal hemorrhage
o Can be vector for Hepatitis B
o Ticks
o Latch onto skin when biting and mouthparts remain on skin after removing
o Intense itching and raised papules
o Don’t apply petrolatum or oil to bite
o Can be vector for:
 Rocky mountain fever: transmitted by wood or dog ticks
Symptoms: Fever, rash, headache, and exhaustion
o Appear 3-12 days after bite
Lyme disease: transmitted by deer tick
• Symptoms: inflammation of joints, heart, and nerves, bulls’ eye
rash, flu and neurologic damage
• Resolves in 3-4 weeks
• RX:
o Amoxicillin 500mg TID
o Cefuroxime Axetil 500mg BID
o Doxycycline 100mg BID
o Initial treatment for 14 days
•

o Chiggers
o Live in trees, shrubs, and grass
o Red papule, intense itching, and hardening of skin
o Attach to skin with bite and release digestive fluid
o Spider
o All are poisonous
o Only black widow and brown recluse can break skin
o BW: intense pain, stiffness of joints, fever, chills, dyspnea, abdominal pain
o BR: all the above plus spreading ulcerated wound
Consideration:
o No OTC for scabies
o RX:
 Permethrin 5% cream (Acticin)
 Lindane 1% lotion
• 2nd line treatment
 Crotamiton 10% cream or lotion (EURAX)
 Antihistamines can be used as adjunct for itching
o Ticks and spider bites must be seen by doctor
o Must be confined to one area to self-treat
Prevention:
o Use covered clothes
o Avoid swamps and standing water
o Use insect repellent
o DEET less than 30% in children
o Citronella, lemon eucalyptus oil, lavender oil
Goals:
o Relieve symptoms
o Prevent infection
Age:
o Must be over 2 years old
Complications:
o Risk of contact dermatitis with use of anesthetics and antihistamines
o Need to limit systemic exposure by avoiding open wounds, occlusive Band-Aids,
prolonged use, heated areas, and extensive application
o Risk of atrophy, acne, and skin eruptions with topical corticosteroids
o Be wary of systemic diseases such as Lyme and RMSF
Pharm:
o Local anesthetics
o Examples:
 Benzocaine, Dibucaine, Pramoxine
o Used for pain and itching
o Use 3-4 times per day 7 days max
o Dosage forms in cream, lotion, aerosol, and lotion
o Topical antihistamines
o Examples:
 Diphenhydramine 0.5-2%
o Used for itching and pain
o Use 3-4 times per day for 7 days max
o Dosage forms in cream, gel, and spray
o Topical hydrocortisone
o Example:
 Hydrocortisone 1%
o Used for itching, pain, and swelling
o Use 3-4 times per day for 7 days max
o Dosage form in creams and ointment
o Not appropriate when infection present
o Counterirritants
o Example:
 Camphor 0.1-3%
 Menthol 0.1-1%
o Used for itching and pain
o Use 3-4 times per day for 7 days max
o Dosage form in lotion and ointment
o Skin protectants
o Examples:
 Zinc oxide
 Calamine
 Titanium dioxide (Not FDA approved)
o May reduce irritation and inflammation
o Mild astringent, weak antiseptic, and absorb fluids from lesions
Non-Pharm:
o Ice pack
o Trim nails to avoid itching
Insect stings
Exclusions:
o Hives, weakness, vomiting
o Allergic response
o Previous sting by honeybee, wasp, or hornet
o Less than 2 years old
Appearance/Feature:
o Honeybees
o Have barbed stringers
o Wasps, hornets, yellow jackets
o No barb so multiple stings
o Africanized killer bees
o Very aggressive and swarming behavior
o Multiple stings increase venom injection
o Greater chance of severe allergic reaction
o Fire ants
o Bite and sting
 Bites inject venom
o Symptoms: Intense itching, burning, tissue necrosis, and vesicle formation
o Limited to no cross-sensitivity with flying insects
Consideration:
o Venomous stings contain an allergic protein
Prevention:
o Avoid perfumes and scents
o Clean up picnics
o Wear shoes
o Destroy nests near home
Goals:
o Relieve pain and itching
o Address allergic reactions
o Hives/rashes
o Burning sensation
Pharm:
o For stings:
o Local anesthetic
o Topical antihistamine
o Counterirritants
o Topical hydrocortisone
o Skin protectants
o Systemic antihistamines
 Not FDA approved
o For allergic reaction:
o Epinephrine
 Epi-pen
• Not full treatment for allergic reaction
 Inject deep into muscle at 90 degree angle and hold for 5-10secs
afterwards massage area
Non-Pharm:
o Ice pack for 10min intervals
o Stinger removal
o Scarping stinger away is the best way
o Meat tenderizer
o Ammonia and baking soda
o Toothpaste
o Papaya
Urushiol induced dermatitis
Exclusions:
o Symptoms worsen
o Rash is extensive
o Face rash and swelling
o Rash on genitals
Appearance/Feature:
o Poison ivy
o Poison oak
o Poison sumac
o Most common form of allergic dermatitis
o 1st exposure is sensitized
o 2nd exposure is hypersensitivity
Consideration:
o Avoid antihistamines
Prevention:
o Get rid of plants near him
Non-Pharm:
o Wash exposed skin with soap
o Cleanse exposed pets
o Cool compress and showers
Lice
Exclusions:
o Secondary infection
o Lice in eyebrows or eyelids
o Pregnancy or breastfeeding
o Active tumors
Appearance/Feature:
o Head lice (Capitis)
o Most common
o Not a vector
o No socioeconomic trend
o Eggs NIT hatch to louse which must feed within 24hours
o Louse bite and produce papule with redness and itching
o NITs easier to spot than lice due to immobility
o Lice die within 48 hours
o Body lice (Corporis)
o Lay eggs in clothes and folds of skin
o Can be vector for Typhus
o Common in people who don’t change or shower
o Pubic lice (pubis)
o Transmitted via clothing and sex
Goals:
o Kill lice
o Remove eggs
Age:
o Older than 2 months
Complications:
o Avoid gasoline treatments
Pharm:
o Pyrethrins 0.33%
o Examples:
 Rid shampoo
 Rid moose
 A-200 shampoo
o Requires retreat 7-10 days
o Ages 2 and older
o Pyrethrins 1%
o Examples:
 Nix cream
o No retreatment required unless more lice found after 10days
 Residual effects for 10 days
o Ages 2 months and older
o Ivermectin 0.5% lotion
o Example:
 Sklice
o No retreatment
o Ages 6 months and older
o Abametpir 0.74% lotion
o Example:
 Xeglyze
o No retreatment required
o Ages 6 months and older
Non-Pharm:
o NIT comb
o Wash clothes in hot water
o Vacuum
o Body hygiene
o Tea tree oil 10% with lavender oil 1%
o Apply weekly for 3 weeks
o Use with caution may cause liver damage and allergic reaction
Fungal Skin Infection
Exclusions:
o Nails or scalp involved
o Face, mucous membrane, or genitals involved
o Diabetes, immune deficiency, or systemic infection
o Bacterial infection
o Exudation
o Fever
o Extensive inflammation
Appearance/Feature:
o Tinea pedis
o Tinea unguium
o In toenails and cannot be self-treated
o Tinea corporis
o Ring worm
o Tinea cruris
o Groin
o Red is acute and hyperpigmented is chronic
o More common in men
o Tinea capitis
o Skull
o 4 subtypes:
 Non-inflammatory
• Small papules surrounding hair shaft
 Inflammatory
• Pain and pruritis
 Black Dot
• Breaks off hair shaft at skin
 Favus
• Patchy hair loss with yellow crust/scales
o Pathogenic fungi:
o Trichophyton
o Microsporum
o Epidermophyton
Goals:
o Symptomatic relief
o Eradicate current infection
o Prevent future infections
Pharm:
o Clotrimazole 1% (Lotrimin AF cream)/ Miconazole Nitrate 2% (Lotrimin AF powder
spray)
o Pedis: Apply twice a day for a month
o Cruris: Apply twice a day for 2 weeks
o Corporis: Apply twice a day for a month
o Dosage forms: cream, spray liquid, spray powder
o Terbinafine 1% (Lamisil)
o Pedis: Apply twice a day for a week for interdigital and 2 times a week on soles
and side
o Cruris: Apply once daily for a week
o Corporis: Apply once daily for a week
o Dosage forms: Cream and Gel
o Tolnaftate 1% (Tinactin)
o Pedis: Apply twice a day for 2-4 weeks
o Cruris: Apply twice a day for 2-4 weeks
o Corporis: Apply twice a day for 2-4 weeks
o Dosage forms: Powder, spray liquid, spray powder, cream, and solution
o Butenafine 1% (Lotrimin Ultra)
o Pedis: Apply twice a day for a week or daily for 4 weeks
o Cruris: Apply once daily for two weeks
o Corporis: Apply once daily for two weeks
o Dosage form: cream
o May take 4-6 weeks for results and may extend treatment
o For sweating choose powder and for hard to reach choose spray
Non-Pharm:
o Limit spread
o Clean skin
o Keep skin dry
o Bitter orange
o Tea tree oil
o Garlic
Acne
Exclusions:
o Moderate to severe
o Rosacea
o Pregnant
o Most OTC category C
o No improvement with 6 weeks
Appearance/Feature:
o Black head: Open comedone
o White head: Closed comedone
Consideration:
o Self-care for mild only
o Refer if no improvement after 6 weeks
Pharm:
o Benzoyl peroxide 2.5-10%
o Used in combination with other treatments
o Example Proactive
o May bleach clothes and hair
o May cause photosensitivity
o Improvement may take 4-6 weeks
o Continue treatment after clearance to prevent new breakout
o Start sparing at day 1-3 to assess sensitivity
o May increase use to 2-3 times a day
o Salicylic acid 0.5-2%
o Not as effective as Benzoyl peroxide
o Example OLAY
o Causes photosensitivity
o Improvement may take 4-6 weeks
o Not for patients with poor circulation, diabetes, or salicylate toxicity
o Avoid long term use
o Start sparing at day 1-3
o Can increase to 2 times a day
o Sulfur 3-10% & Resorcinol 2-8%
o Not as effective as benzoyl
o Example Stay clear
o Use 1-3 times per day
o May stain skin
o Avoid sulfa allergic patients
o Adapalene (Differin) Rx
o Not as effective as Tazarotene
o Causes photosensitivity
o Use once a day at bedtime
o Topical retinoids Rx
o All dosed once daily at bedtime
o More effective than OTC
o Vitamin A analogs
o Dapsone (Aczone) 5-7.5% gel
 Category C for pregnancy
 ADR: local irritation and peeling
 Oral linked to anemia
 Reassess after 12 weeks
 Use pea sized amount once daily for 7.5% and twice daily for 5%
o Azelaic acid (Azelex) 20% cream




Category B for pregnancy
Use twice a day
May lighten pigmentation of skin or cause irritation
Mild photosensitivity
Non-Pharm:
o Wash with mild soap
o Stay hydrated
o Limit high glycemic foods
WART
Exclusions:
Appearance/Feature:
o An epidermal infection of HPV
o Common: Viral induced and found on hands and feet
o May be single or grouped papules
o Cauliflower like appearance
o HPV types 1,2,4,5,7,8,10
o Plantar: Viral induced found on sole of foot
o Flat, circular, surrounded by thick skin
o Thrombosed capillaries appear as dots beneath surface
o May coalesce into mosaic warts
o Flat
o Mosaic
o Myrmecia
Consideration:
o Spontaneous resolution within 2 years in 40% of patients
o Most treatments 60-70% effective at 3 months none are 100%
o Poor immune patients may never heal
Prevention:
o Wash hands after wart contact
o Don’t walk barefoot
o Don’t cut or probe wart
o Don’t contaminate wart with clothing
Goals:
Age:
Complications:
Pharm:
o Salicylic acid
o Only approved OTC
o First line for common, flat, and plantar
o Plaster disk or pad 40%
o Collodion 17%
o Imiquimod (Aldara) Rx
o Approved first line for flat
o Expensive
o 5% cream
o Mixed results of efficiency
o Bleomycin (Blenoxane)
o 3rd line treatment for common and plantar
o May cause pain, pigmentation changes, scarring, Raynauds phenomenon
o Expensive and must be administered in doctor’s office
o 15ml vial for injection reconstituted with 30ml of saline
Non-Pharm:
o Cryotherapy
o Dye laser
o Surgical
o Oral/topical retinoids
o Intralesional immunotherapy
o Duct tape