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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 Prickly Heat Dermatitis
o Often caused by a combination of factors: o Also known as heat rash or miliaria
Occlusion by diaper o May occur in patients of any age
Moisture due to incontinence o Caused by blocked sweat glands
Urine and fecal bacteria Sweat cannot be released from the pores
GI enzymes and bile salts Leads to dilation/rupture of the pores and
Skin pH changes inflammation of the dermis
Mechanical friction, skin chaffing and irritation o Most commonly occurs in hot, humid conditions, during
Diaper Dermatitis Presentation vigorous work or exercise and/or in other conditions that
o Irritated, erythematous, shiny or wet appearing lesions cause perfuse sweating
Perineum area, buttocks, upper thighs and/or lower May also occur due to tight-fitting or occlusive
abdomen clothing
o Sever cases can progress to maceration, skin erosion, Prickly Heat Dermatitis Presentation
vesicles or pustules and secondary infection o Raised, erythematous, pinpoint-sized papules with itching,
o Irritated, erythematous, shiny or wet appearing lesions stinging or burning
Perineum area, buttocks, upper thighs and/or lower o Common sites:
abdomen Axillae
Appearance may be similar to skin infection or Chest
allergic contact dermatitis, so its important to assess Upper back
other clinical features Back of neck
o Rash can appear quickly on previously normal looking skin Abdomen
Diaper Dermatitis Treatment Inguinal area
o Goals: relieve symptoms, eliminate the rash, minimize risk Prickly Heat Treatment
of infection, prevent recurrence of rash o Goals: remove causes of the rash, eliminate rash, relieve
o Uncomplicated and mild to moderate cases may be self symptoms
treated o Non-pharmacologic: remove the cause
o Non-pharmacologic: Wear loose, lightweight clothing
Frequent diaper changes Avoid occlusion of skin
Gentle wiping with mild infant wipes Move to a cooler environment
Rinse skin with water and gently dry or allow to air o Pharmacologic: used for symptom relief
dry Water-washable skin emollients/lotions
Utilize disposable diapers with moisture wicking Colloidal oatmeal products
materials Good option for children/infants
Minimize or eliminate use of washable cloth diapers Topical steroids (hydrocortisone)
o Pharmacologic: May be used in adults only if 10% body surface
Skin protectants primary pharmacologic treatment is affected
Lubricate the skin Contraindicated for infants
Form a protective barrier along the skin Prickly Heat Product Selection and Counseling Points
Very good safety profile o Goal is to relieve symptoms while not blocking skin
o NOT APPROPRIATE for diaper dermatitis: exposure to the air
Topical antibiotics o Recommend creams or lotion products, not ointments
Topical antifungals Product should be water-washable
Topical analgesics Apply a thin layer only
Topical steroids Avoid over application
FDA-Approved Skin Protectants o Powder products absorb moisture and dry the skin
o Allantoin, Calamine, Cocoa butter, Cod liver oil, Colloidal May be used to prevent prickly heat
oatmeal, Dimethicone, Glycerin, Hard fat, Kaolin, Lanolin, Not recommended for active prickly heat
Mineral oil, Petrolatum, Topical cornstarch, White o Expect improvement within 24 hours
petrolatum, Zinc acetate, Zinc carbonate, Zinc oxide Exclusions to Self-treatment: Diaper Dermatitis and Prickly
Counseling Points for Skin Protectants Heat
o Use in combination with non-pharmacologic measures o > 7 days duration or no improvement after 7 days of
o Apply a liberal amount of skin protectant over the entire treatment
diaper area with each diaper change o Diaper dermatitis type rash occurring outside of diaper area
o Several types of products are available including o Broken skin, oozing, bleeding, vesicle formation and/or
ointments, creams, pastes, powders presence of pus
Avoid use of loose powder products near infants face o Evidence or suspicion of infection
o Should begin to see improvement within 24 hours o Chronic or frequent recurrence
o Immunosuppressive conditions
o Signs of heatstroke o Treatment must involve both non-pharmacologic measures
Patient Case: L.B. is an 8 month old female patient with a and pharmacologic therapy
bright red patchy rash covering her buttocks that appeared o Goals: eradicate pinworms, relieve symptoms, prevent
rather suddenly according to her mother. There is no reinfection and transmission of infection
maceration, vesicles or oozing. Treatment Non-pharmacologic
o What is the most likely cause of L.B.s presentation? o Avoid scratching
o Can this condition be self treated? o Promote good personal hygiene
o What would you recommend for L.B.? Bathe daily in the morning, rather than at night
o What are some important counseling points to tell L.B.s Wash hands regularly
mother? Keep fingernails clean and trimmed
o Change and wash bed sheets, clothing, towels daily in hot
Pinworm Infection water and dry in a hot dryer during treatment and for
o Common helminthic infection caused by Enterobius several days afterward
vermicularis o Mop, clean and vacuum daily during treatment and for
Intestinal parasite several days afterward
Small, thread-like, white worm (~1 cm in length) Treatment Pharmacologic
o Transmitted by direct anal-oral transfer of eggs o Pyrantel pamoate: nonprescription product
Female pinworms migrate out of the colon and lay o Albendazole: prescription-only product
eggs in the perianal area o Mebendazole: no longer available in the U.S.
Infection (or re-infection) occurs when the eggs are Pyrantel Pamoate
ingested o 90-100% effective in eliminating pinworm infection
o Most common in children Not effective on eggs
Pinworm Lifecycle 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
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
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,
Presentation repeat x1 in 2 weeks
o Intense itching in the perianal or perineal area, most often Counseling Points
during the night o Encourage strict hygiene measures
Some patients may be asymptomatic o Treatment should include both non-pharmacologic and
Major infestations may be associated with more severe pharmacologic measures
symptoms such as abdominal pain, restlessness, o Entire family/household should receive treatment
insomnia, intractable itching, diarrhea, anorexia o Symptoms should resolve within two weeks
o Potential complications include: o Physician should be contacted for non-resolution of
Secondary bacterial infection symptoms after two weeks
Urinary or genital tract infection Exclusions to Self-treatment
Appendicitis o Children < 2 years old or < 25 pounds unless self-treatment
Diagnosis recommended by physician
o If nocturnal perianal itching is present, the infection can be o Pregnant or breast feeding
confirmed by: o Liver dysfunction
o Nocturnal visualization of worms around perianal area or: o Symptoms inconsistent with pinworm infection or
Tape test and microscopic examination helminthic infection other than pinworm suspected
Treatment o Need for repeated dose after first treatment
Patient Case: A.V. is a 6 year old female child who attends 1 st o Avoid sharing personal items and footwear with others
grade. She weighs 22 kg and has no significant past medical Treatment Pharmacologic/Alternative
history. Her father reports that the child had been complaining o Pharmacologic
of being awakened by perianal itching at night. On the advice of Salicylic acid
the pediatrician, a visual exam was performed one night and Cryotherapy
small white worms were noted around the childs anal area. o Alternative therapies
o What non-pharmacologic and pharmacologic therapies Complementary therapies
should be recommended for A.V.? Duct tape
o Within what timeframe would symptoms be expected to Salicylic Acid
resolve? o Topical keratolytic product that works by causing
o What are some other important counseling points? destruction of hyperkeratotic cells
o May be used on common or plantar warts
Warts o Easy to use, accessible, affordable and effective product
o Very common o Improvement often noted after a few weeks of regular use
o Caused by human papillomaviruses (HPV) o Adverse effects: local irritation, risk of systemic toxicity
o Affect the epidermis (rare)
Some types of warts may affect mucous membranes Salicylic Acid Product Selection
o Long incubation period (up to 8 months) o Several formulations (and strengths) available:
o Transmitted by person-to-person contact, contact with Salicylic acid in plaster vehicle (12-40%)
contaminated surfaces, or autoinoculation Salicylic acid in collodion vehicle (17%)
Presentation 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 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 All products may be used for up to 12 weeks for wart
o Prior history of warts treatment
o Immunosuppression o See individual product packaging for exact, product
o Use of swimming pools and public bathing facilities specific instructions
o Walking barefoot Cryotherapy
o Biting of fingernails o Freezing of tissue leads to a local inflammatory response
o Meat handling and destruction of the infected cells
Treatment Intracellular ice crystals form
o Many warts will resolve on their own without any A blister will form underneath the wart and the wart
treatment will eventually fall off
23% resolve within 2 months o Available therapies include:
30% resolve within 3 months Liquid nitrogen must be administered by a
More than two-thirds resolve within 2 years healthcare provider
o Wait-and-see approach may increase the risk of Dimethyl ether/propane products available without a
transmission or autoinoculation prescription
o Goals: remove wart, reduce risk of transmission, prevent o Self-treatment may be repeated every 2-3 weeks until:
recurrence of warts Resolution of the wart or Maximum number of total
Treatment Non-pharmacologic treatments reached (typically 3-4 total treatments for
o Avoid cutting, shaving or picking at warts most products)
o Wash hands after touching warts o Do not exceed 3 months duration of treatment
o Keep warts covered o Adverse effects:
o Avoid walking barefoot Pain
o Keep feet clean and dry Damage to surrounding healthy skin,
o Dry warts with a separate towel 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
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: