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8 Cards in this Set
- Front
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ATOPIC DERMATITIS
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Avoidance of Triggers1.
• Reduce exposure to known allergens. 2. • Wear smooth, comfortable, breathable clothing. 3. • Ceramide-containing creams, such as EpiCeram or TriCeram, have added benefit over other emollients. 4. • Virgin coconut oil reduces Staphylococcus aureus colonization. 5. • Avoid known food allergies. (The most common foods triggers of atopic dermatitis are egg, soy, milk, wheat, fish, shellfish, and peanut.) 6. • Infants at high risk who cannot exclusively breast-feed should use hydrolyzed formula (broken down proteins) in the first 4 months of life. Examples of hydrolyzed formulas include Nutramigen LIPIL, Pregestimil, and Alimentum Advance. 7. • Drink 3 cups of strong oolong tea daily. 8. • Support groups 9. • Coping skill educational program 10. • Psychotherapy 11. • Vitamin D3: 1600 units daily 12. • Vitamin E: 600 units daily 13. • Docosahexaenoic acid/eicosapentaenoic acid: 2 to 4 g daily 14. • Gamma-linolenic acid: 500 mg daily 15. • Lactobacillus rhamnosus: 20 billion CFUs daily for an atopic mother prenatally and postnatally for prevention of atopic dermatitis in the infant 16. • 2% Glycyrrhetinic acid (Atopiclair or others) applied three times daily 17. • Topical formulations of Hypericum perforatum (St. John’s wort), chamomile, rosmarinic acid, or Oregon grape root applied twice daily 18. • Vitamin B12 0.07% cream used twice daily 19. • Coal tar preparations applied twice daily to chronic or lichenified lesions 20. • Antihistamines • Doxepin cream: twice daily to affected areas 21. • Diphenhydramine: 12.5 to 50 mg orally every 6 hours 22. • Hydroxyzine: 10 to 50 mg orally every 6 hours 23. • Loratadine: 10 mg orally daily 24. • Antimicrobials • Dilute bleach baths (½ cup per full bathtub) are recommended twice weekly for 5 to 10 minutes combined with mupirocin 2% intranasally 5 consecutive days each month to reduce S. aureus colonization. 25. • Consider ketoconazole, 200 mg twice daily for 10 days, for head or neck involvement. 26. • Consider skin culture for bacteria and herpes or empirical treatment for recalcitrant lesions. 27. • Corticosteroids • Triamcinolone 0.1% ointment: twice daily for up to 2 weeks for flares, then up to twice daily on weekends to maintain remission 28. • Hydrocortisone 1% ointment: used on thin skin at higher risk for adverse events (face, neck, axilla) 29. • Topical immunomodulators • Tacrolimus 0.03% ointment: twice-daily short-term use for patients older than 2 years old 30. • Tacrolimus 0.03% ointment: three times weekly to maintain remission in patients older than 2 years old 31. • Tacrolimus 0.1% ointment: twice-daily short-term use for patients older than 15 years old 32. • Pimecrolimus 1% cream: twice-daily short-term use |
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PSORIASIS
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General Measures1.
• Gentle skin care: Avoid hot water for bathing and use gentle cleansers and emollients and colloidal oatmeal. 2. • Narrow-band ultraviolet B or ultraviolet B 3. • Ultraviolet A alone or with psoralen (PUVA) 4. • Climatotherapy and balneophototherapy 5. • Antiinflammatory diet: 6. • Fish oil or oily fish: This is also useful as an adjuvant to decrease side effects of systemic retinoids and cyclosporine. Consider 2 to 3 g/day. 7. • Zinc: No good evidence has indicated a benefit in psoriasis; however, some clinicians do report a benefit. The dose is 15 to 30 mg/day. 8. • Inositol: This may be useful in patients with lithium-induced psoriasis. The dose is 6 g/day, with monitoring of psychiatric disease in patients with bipolar disorder. 9. • Capsaicin for itching: A 0.025% or 0.075% cream is applied three or four times/day. Patients may experience stinging or burning during initial applications. 10. • Aloe vera: This may help decrease scaling and redness. 11. • Glycyrrhetinic acid 1% to 2% formulation: This may enhance the effect of topical steroids by inhibiting their degradation. 12. • Curcumin: The effective dose is unclear. One study looked at 150 mg three times a day. 13. • Milk thistle: The dose is 140 mg (70% silymarin) two to three times/day. It is best used as a hepatoprotective agent in patients taking hepatotoxic medications. 14. • Keratolytics, to decrease scale and plaque thickness: • Salicylic acid (2% to 10%) twice daily 15. • Urea (up to 40%) twice daily 16. • Alpha-hydroxy acids (glycolic and lactic acids) twice daily 17. • Tar: 2% to 20% preparations 18. • Anthralin: 0.5% to 1% preparation applied for 10 to 30 minutes once or twice daily, to protect normal skin from irritation 19. • Calcipotriene (Dovonex): 0.005% cream, lotion, or ointment twice daily, limited to no more than 100 g/week 20. • Tazarotene gel (Tazorac): 0.05% to 1% gel applied at bedtime 21. • Topical steroids: See Table 67-4. Clinician should pay attention to the location treated and watch for side effects. 22. • Methotrexate: 10 to 15 mg/week; single weekly dose or divided into three doses given 12 hours apart 23. • Cyclosporine: started at 5.0 mg/kg/day, with dosage tapered by 0.5 mg/kg/day to the lowest required dose 24. • Acitretin (Soriatane): 10, 25, or 50 mg daily 25. • Biologic immune response modifiers: • Alefacept (Amevive): 15 mg/week intramuscularly for 12 weeks 26. • Etanercept (Enbrel): 50 mg once or twice a week subcutaneously 27. • Efalizumab (Raptiva): 1 to 4 mg/kg once a week subcutaneously 28. • Infliximab (Remicade): 5 mg/kg over 2 to 3 hours intravenously at weeks 0, 2, and 6 and then every 8 weeks thereafter 29. • Ustekinumab (Stelara): 45 or 90 mg as a subcutaneous injection at weeks 0 and 4 and then every 12 weeks thereafter 30. • Meditation: Great for stress reduction or minimization 31. • Hypnosis: Most potential benefit for hypnotizable patients 32. • Traditional Chinese medicine: Please see the text Dermatology in Traditional Chinese Medicine, by Xu Yihou,67 for more detailed and complete information on and understanding of traditional Chinese medicine. 33. • |
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PSORIASIS
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This is a summary of therapeutic options for urticaria. Laboratory investigation should be directed by the history and physical findings. Particular attention to associations with systemic disease is warranted in patients with chronic urticaria. General Measures1.• Identify and avoid any precipitating factors, if possible. Activity and ingestant diaries may be particularly useful in this endeavor. 2. • Use topical measures, including a cool, calm environment, loosely fitting, comfortable clothes, baths with cornstarch, colloidal oatmeal (Aveeno), or baking powder. 3. • Avoid allergenic foods and foods high in histamine (see Table 68-1). 4. • Consider an elimination diet. 5. Emmenthal 6. Harzer 7. Gouda 8. Roquefort 9. Tilsiter 10. Camembert 11. Cheddar 12. Anchovies 13. Mackerel 14. Herring 15. Sardines 16. Tuna 17. Ham 18. Salami 19. Sausage 20. • Quercetin: 400 mg orally twice daily before meals 21. • Butterbur (Petadolex): 75 mg orally twice daily 22. • Sarsaparilla: 1 to 4 g as dried root or tea three times daily; liquid extract (1:1 in 20% alcohol or 10% glycerol): 8 to 15 mL three times daily 23. • Stinging nettle: 300 mg three times daily 24. • Peppermint: 0.2 to 0.4 mL oil three times daily between meals or equivalent in enteric-coated tablets 25. • Ginkgo biloba for cold-induced urticaria: 120 mg/day standardized extract 26. • Valerian root for stress-related urticaria: 200 to 300 mg/day 27. • Antihistamines: H1-receptor blockers alone or in combination with H2-receptor blockers 28. • First-generation • Hydroxyzine: 50 mg one to four times daily 29. • Diphenhydramine: 25 to 50 mg every 6 to 8 hours 30. • Chlorpheniramine: 4 to 8 mg twice daily. 31. • Promethazine: 12.5 to 25 mg every 6 to 8 hours 32. • Second-generation • Loratadine (Claritin): 10 mg once or twice daily 33. • Fexofenadine (Allegra): 60 to 180 mg once or twice daily 34. • Cetirizine (Zyrtec): 10 mg once or twice daily 35. • H2-receptor antagonists • Ranitidine (Zantac): 150 to 300 mg twice daily 36. • Famotidine (Pepcid): 20 to 40 mg one to twice daily 37. • Cimetidine (Tagamet): 200 to 400 mg one to four times daily 38. • Doxepin: 10 to 75 mg before bed 39. • Leukotriene inhibitors • Zafirlukast (Accolate): 20 mg twice daily 40. • Montelukast (Singulair): 10 mg daily 41. • Zileuton (Zyflo): 600 mg up to four times daily 42. • Corticosteroids: 60 mg/day for 2 to 3 days, then tapered over 1 to 2 weeks 43. • Cyclosporine: 3 mg/kg/day for 6 weeks, 2 mg/kg/ day for 3 weeks, and 1 mg/kg/day for 3 weeks. Appropriate monitoring is essential. 44. • Relaxation: Good for everyone! 45. • Hypnosis, especially for people classified as hypnotizable 46. • Please see the text Dermatology in Traditional Chinese Medicine, by Xu Yihou,35 for more detailed and complete information on and understanding of TCM. 47. • Please also see Key Web Resources for Web sites listing traditional Chinese medicine practitioners. |
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RECURRENT APTHOUS ULCER
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The most important issue in dealing with recurrent aphthous ulcers (RAUs) is to exclude systemic conditions, particularly Behçet’s syndrome (mouth, genital, and eye ulcers). Because the origin of RAUs is multifactorial, a simple list of treatments is not applicable; a good history helps focus on the triggers and can lead to a specific treatment plan. The following is a guide to the most common causes and treatments of RAU. Laboratory Evaluation1.• Identification of nutritional deficiencies should be the first step in treating RAUs. 2. • Order measurements of serum ferritin, red cell folate, and serum vitamin B12. Replace these nutrients if the patient is deficient. 3. • Giving 250 mg of vitamin C with the iron is often helpful to assist in iron absorption. 4. • If you suspect celiac disease, assess the patient for tissue transglutaminase immunoglobulin A and antiendomysial antibodies. 5. • Identify any foods that trigger the RAUs and consider elimination. 6. • Consider using honey, 20 mL before, during, and after radiation therapy of the head and neck to reduce the severity of mouth ulcerations. 7. • B vitamins (vitamins B1, B2, B6, B12) • Because the cost and potential harm of B vitamins are low, a 3-month trial of one B-50 complex vitamin pill daily can be used to see whether the frequency of RAUs is reduced. A B-50 complex vitamin contains approximately 50 mcg or mg of each B vitamin. 8. • Vitamin B12, 1000 mcg sublingually daily for 6 months, has been found to reduce the incidence of ulcers. 9. • Glutamine • Mix 4 g of powder in water, swish, and swallow four times/day. 10. • This is best for RAUs resulting from severe disease or injury or in patients undergoing chemotherapy. 11. • Licorice (Glycyrrhiza) mouthwash: Mix ½ teaspoon of licorice extract in ¼ cup of water; swish and expel four times/day. 12. • CankerMelt disks contain 30 mg Glycyrrhiza extract. The disk is applied to the ulcer and allowed to dissolve over time; then a new disk is applied every 6 hours. 13. • Mercurius solubilis is indicated if the RAUs are associated with foul breath and increased salivation. Use 6X or 6C potency four times/day until healing begins. 14. • Borax is indicated if the RAUs are brought on with citrus or acidic foods. The mouth usually feels dry even though some saliva may be present. Use 6X or 6C potency four times/day until healing begins. 15. • Arsenicum album is indicated in patients whose RAUs are brought on by stress and eased with hot drinks. Use 6X or 6C potency four times/day until healing begins. 16. • Because stress is often a component of RAUs, stress reduction techniques, such as meditation and guided imagery, are usually advisable to include in management. 17. • Topical Therapy • Amlexanox (Aphthasol) 5% paste: 0.5 cm applied to sore four times daily 18. • Triamcinolone acetonide 0.1% in carboxymethyl cellulose paste (Kenalog in Orabase): 0.5 cm applied to sore three to four times daily 19. • Viscous lidocaine (Xylocaine 2% solution): 15 mL swished every 3 hours as needed for pain 20. • Chlorhexidine gluconate 0.12% oral solution (Peridex or Periogard oral rinse): 15 mL rinsed and expelled twice daily 21. • Tetracycline 500 mg/5 mL to make 60 mL, fluocinolone acetonide solution (Synalar) 30 mL, and diphenhydramine syrup (Benadryl) 60 mL, mixed together to make 150 mL: 10 mL swished and expelled four times daily 22. • Systemic Therapy • Colchicine: 0.6 mg twice daily, increased to three times daily as tolerated in terms of gastrointestinal side effects 23. • Prednisone: 40 to 60 mg/day for 5 days 24. • Thalidomide: 200 mg/day; used only for most severe cases 25. • Premedicate with 2% viscous lidocaine and paint the ulcer once with silver nitrate stick until it turns white. 26. • This technique helps reduce pain but not ulcer duration. |
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SEBORRHEIC DERMATITIS
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The following is an outline of therapeutic options for the treatment of seborrheic dermatitis. Determining which factors lead to the disease presentation in a given patient may improve the chances of success of a given therapy. For more severe or resistant cases, a progressive, sequential approach with multiple therapeutic avenues is recommended, with either intensification of treatments or addition of systemic pharmacologic agents, as indicated by the clinical response. Antidandruff Shampoos1.• Zinc pyrithione, selenium sulfide (Selsun), tar, or ketoconazole (Nizoral) shampoo is used for 5 minutes two or three times/week. 2. • If the patient has used one type with no clinical improvement, another can be tried. 3. • Ketoconazole cream 2% (Nizoral) or another pharmacologic or herbal substitute works well on the face and nonscalp areas. 4. • Eicosapentaenoic acid and docosahexaenoic acid (fish oils) can be added at 1 to 2 g/day and titrated to clinical improvement. 5. • Other sources of omega-3 essential fatty acids—oily cold-water fish, such as salmon and sardines, three to five servings/week, and flaxseed oil, 1 teaspoon/day—can be used. 6. • Vitamin E 400 units/day should be given with these oils to prevent oxidation. 7. • Vitamin B complex, vitamin B6 500 mg, and biotin up to 8 mg/day may be beneficial in patients with resistant cases. 8. • Caprylic acid is taken at 100 to 200 mg two to three times/day. 9. • A diet low in yeast and simple carbohydrates, especially one that eliminates bread, cheese, wine, beer, fermented foods, and starches, is helpful in patients with persistent cases. 10. • Some improvement may result from removal of other food allergens. 11. • Adding probiotic bacteria such as Lactobacillus acidophilus, one capsule/meal, or live-culture yogurt may also help. 12. • The antiyeast botanicals grapefruit seed extract and Artemisia annua may be used at two to six capsules/day. 13. • Undecenoic acid, derived from the castor bean, is another antiyeast product (Formula SF 722 [Thorne Research, Sandpoint, Idaho]), used at two to six capsules/day. 14. • Nystatin is used in slowly increasing doses from 0.5 to 6 million units/day. 15. • Fluconazole (Diflucan) is taken at 100 to 200 mg/day for 2 weeks, for resistant cases. This agent is best used after dietary, herbal, and supplement methods have been employed to reduce the yeast flora and to attenuate the ecologic factors favoring yeast growth. 16. • Triamcinolone solution or betamethasone valerate foam (Luxiq) once or twice daily can be used to relieve pruritus and inflammation. |
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ACNE ROSACEA
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Mind-Body Medicine (for acne vulgaris and rosacea)1.
• Practice stress management and relaxation techniques 2. • Maintain a diet low in glycemic load 3. • Limit or eliminate dairy consumption 4. • Maintain a diet high in omega-3 fatty acids with the option of flaxseed or fish oil supplementation 5. • Brewer’s yeast: 2 g three times daily 6. • Zinc gluconate: 30 mg daily 7. • Tea tree oil: 5% to 15% solution or gel, applied topically once daily 8. • Azelaic acid: 20% cream or 15% gel, applied topically twice daily for acne vulgaris or rosacea 9. • Salicylic acid: applied topically one or two times daily for acne vulgaris 10. • Retinoids: applied topically once nightly for acne vulgaris 11. • Topical antibiotics (benzoyl peroxide, clindamycin, erythromycin, sulfacetamide, metronidazole) for acne vulgaris and rosacea (see Table 71-1) 12. • Oral antibiotics (erythromycin, tetracycline, doxycycline, minocycline) for acne vulgaris and rosacea 13. • Isotretinoin: 0.5 to 1 mg/kg/day, taken orally once or in two divided doses daily for acne vulgaris 14. • Laser therapy for associated erythema and telangiectasias 15. • |
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PAPILLOMA VIRUS AND WARTS
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Diet and Lifestyle1.
• Balanced, whole-food diet that consists of vitamin C, vitamin E, carotenoids, and folic acid. Also include lots of dark green and yellow vegetables and fruits. 2. • Hypnotherapy 3. • Duct tape 4. • Topical green tea extract ointment (Veregen) 5. • Vitamin C: 1000 mg two times daily 6. • Vitamin E: 400 units/day 7. • Folic acid: 400 mcg/day 8. • Topical salicylic acid: 15% to 20% preparations, applied daily for 12 weeks 9. • Topical podophyllotoxin (podofilox): 0.5% gel or solution, applied twice daily for 3 days, followed by 4 days of no treatment, then repeated up to four cycles 10. • Topical trichloroacetic acid: 80% to 90% preparations, applied weekly by physician for 4 to 6 weeks 11. • Cryotherapy 12. • LEEP/LLETZ |
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