Rashes

Rashes

Rashes are another common reason for primary care visits among all age groups. It is a necessary skill for primary care providers to assess and diagnose common causes of rashes, such as; viral, fungal, bacterial, immunological, and other pathological causes. Prescribing pharmacological/ non-pharmacological interventions, performing simple procedures such as I&D, punch biopsy, cryotherapy, and suturing, making referraletc. are also essential roles of a primary care provider. In this module, we will review some of the common dermatological conditions and their management.

Stage 1

Abstract Conceptualization

Abstract Conceptualization

Stage 2

Active Experimentation

Active Experimentation

Patient Assessment and History Collection

During patient assessment, NP will inspect/ palpate the skin, notice the shape and configuration of lesions, and collect detailed history regarding the duration of lesions, family history of cancer, sun light exposure etc. Assess whether the rashes are discrete, grouped, annular, confluent, gyrate, target, polycyclic, or zosteriform. Notice the nature of the rashes such as: macules, papules, nodules, tumor, wheal, vesicle, cyst, pustule, bulla, or scaly. Always confirm if there are any s/o systemic illness, travel history, tick/ flea bites etc. In case of any systemic illness with confusion, meningeal signs, cardio- pulmonary complications etc., arrange emergency medical service.

1. Contact dermatitis

It is a cutaneous response due to direct exposure of the skin to an irritant (irritant dermatitis) or allergens (allergic dermatitis). Irritants dermatitis is a nonimmunological response of the epidermis to chemical such as soaps, detergents; whereas, in allergic dermatitis, an allergic response is produced, and which cause cutaneous inflammation. Common allergens include nickel, hair dye, latex gloves etc. Contact dermatitis management include: avoid the allergen contact, prescribe topical steroid (e.g. hydrocortisone 2%), calamine lotion, antihistamine (Benadryl); if no improvement with topical steroid application,antihistamines etc., prescribe oral steroid (Prednisone at 50mg/ kg/ body wt) and taper off over 10-14 days.

2. A topic dermatitis

Atopic dermatitis is commonly known as eczema. Defect in skin barrier with the dysregulation of the immune system on a genetically and environmentally susceptible background is presumed to be the etiological reason of eczema (1). Family history of atopic triad (dermatitis, asthma, and allergic rhinitis), exposure to allergens (food allergens, environmental allergens), skin irritants, and stress are some of the predisposing factors of eczema. To learn more about pharmaceutical management of eczema, follow the link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582672/. If a superimposed bacterial infection (impetigo) is suspected, treat with a topical antibiotic or an oral antibiotic, as necessary. Acute weeping dermatitis, crusted, and small superficial pustules may indicate bacterial dermatitis.

3. Acne Vulgaris

It is a disorder of the sebaceous glands and hair follicles. Adolescent age group, external skin irritants, hormones, andweather conditions (hot, humid weather) are the common high-risk factors. It can be classified as mild (comedones open &closed), moderate (comedones with pustules and papules), and severe (nodules, cysts, and scars) (2). Acne management/ classification can be viewed in here: http://www.cmaj.ca/content/188/2/118

4. Tinea Corporis

It is a fungal infection of the skin tissue. It appears as scaly, itchy, patch with circular shape. Tine capitis- Tinea infection of the scalp; Tinea cruris- well demarcated lesion on groin; Tinea pedis- scaly, erythematous vesicle on feet, between ties with skin peeling and pruritus; Tinea unguium (onychomycosis)-thickening and yellowing of toe nail or fingernail. Topical antifungal is used to manage tinea corporis; tinea pedis is treated with Lamisil 1% cream, Lamisil 250mg po OD (6 weeks for finger nail, 12 weeks for toe nail); tinea capitis is managed with oral antifungal (Griseofluvin 500mg po ODx 4-8 weeks for adults, 10-20mg/ kg/ day for children) (7).

5. Tinea versicolor

It is a fungal infection of the skin caused by Pityrosporumorbiculare which causes skin discoloration, forming round or oval macule; responds well to selenium sulfide 2.5% (apply ODx12 days)

6. Candidiasis

It’s a fungal infection of skin and/or mucus membrane, caused by Candida Albicans). Candidiasis of oral mucosa presents with white patch on the tongue with or without redness. Thick white cottage cheese like vaginal discharge with out with out vaginal itching indicates vaginal candidiasis. Erythematic rash with erosions seen male genitalia can be due to candidiasis. Oral candidiasis is treated with oral nystatin (for infants 2 ml q6 hrs, and 5ml for adults). Vaginal candidiasis is treated with topical antifungal (clotrimazole 1%, miconazole 2%, or fluconazole 150mg PO ODx1) (7).

7. Hand foot mouth

This is a viral infection (coxsackie virus A16), characterized with vesicular lesions on the hand, feet, and oral mucosa. Its transmitted via orofecal or respiratory route. The incubation period is approximately 4-6 days. No pharmacological treatment is recommended other than fever management and supportive treatment. Assess for s/s of meningitis.

8. Herpes Simplex Virus

Herpes Simplex Virus- It is manifested by vesicular lesions of the mucus membrane with burning, tingling, pain. Oral lesions are usually caused by HSV-1, and genital lesions by HSV-2; however, it’s quite possible for HSV-1 lesions to cause genital lesions & HSV-2 to cause facial lesions as well. Initial episode is treated with Valacyclovir 1000mg BID x 7 days; recurrence dose is 500mg po BIDX3 days. Pregnant patients with h/o HSV need to be given suppression treatment at 36 weeks (3).

9. Warts

Wart (verruca vulgaris) is an elevation of the epidermal layer of the skin caused by papilloma virus. Most warts resolve within12-24 hrs. Filiform wart- thin threadlike projected papule on face, lips, eyelid, nose etc.; Flat wart-flat topped, flesh colored papule 1-3mm in diameter, with smooth surface; Plantar wart- firm papule, 2-3 cm in diameter, skin with verrucous surface & tenderness. Applying duct tape, compound W (OTC), and cryotherapy are the common modes of treatment.

10. Herpes Zoster (Shingles)

It is manifested by painful, unilateral vesicular lesions, following one body dermatome. After the initial attack of chicken pox, the virus remains dormant in the body. Shingles rashes appear when varicella virus get reactivated in the dorsal root of ganglia. Antiviral should be initiated within 24-48 hrs. It is treated with valacyclovir 1000mg TIDx 7 days; Gabapentin is used for pain management (4). Postherpetic neuralgia is one of the common complications of Herpes Zoster.

Kawasaki disease

Kawasaki disease is a mucocutaneous lymph node syndrome that affects children. Common symptoms include: fever, rash, swelling of the hands and feet, irritation and redness of the whites of the eyes, swollen lymph glands in the neck, irritation and inflammation of the mouth, lips and throat. Make referral for urgent pediatric consultation as some cases may cause permanent heart conditions (5).

Scarlet Fever

Scarlet fever is caused by GroupA B hemolytic streptococcus (GABHS). The s/s include strawberry tongue, sand paper rash along with fever, tonsillar enlargement and exudates. The classic ‘sand paper rash’ appears redand feels like fine sandpaper. The rash usually appears 24 hours after the fever starts. The rash begins on the chest and abdomen and then spreads over the rest of the body within 1 to 2 days (6).

11. Actinic Keratosis

These rashes appear on sun exposed areas with a red-tan scaly plaque appearance. They are premalignant and may develop in to squamous cell carcinoma.

12. Seborrheic Keratosis

The rashes appear thick, raised, scaly, warty, with a ‘stuck on’ appearance. They are benign lesions.

13. Basal cell carcinoma

Usually starts as a skin colored papule with a translucent top and overlying telangiectasia. Its slow growing; refer to dermatology for excision.

14. Malignant Melanoma

Arise from pre existing nevi. It appears as brown, tan, black, pink- red,purple of mixed pigmentation with irregular borders. It is a rapid progressing lesion.

15. Squamous cell carcinoma

Erythematous, scaly patch with sharp margins; central ulcer with surrounding erythema develops eventually.

Stage 3

Concrete Experimentation

Concrete Experimentation

SOAP note

4yr old fe with low grade fever x 2 days

No sore throat

No otalgia, vomiting, or GI/GU symptoms

Since yesterday, noticing rashes on b/l hand

Attending a day care

Contact with other children “rashes” at day care

o/e

NAD

Temp- 37.6C

RS-clear, GAEBL, no adventitious breath sounds

Ear-Mild erythema b/l TM- wnl

Nasal mucosa-swollen, erythematous

No neck stiffness

Derm- popular rashes noted on b/l hands, feet, and peri oral

A

Hand foot mouth syndrome

P reassurance given

Fever management

Discussed mode of transmission, prevention of transmission

In case of high fever, neck stiffness, lethargy, vomiting, should seek immediate medical help

Stage 4

Reflective Observation

Reflective Observation

Student Activity

Write a reflection on your learning experience with dermatological conditions/ management? Provide a case/cases to illustrate your learning experience; use Kolb’s learning cycle to narrate your learning cycle?

Resources

Watch the following video that explains common dermatological conditions in primary care:

Watch common skin cancer, signs and symptoms in here:

Watch common pediatric dermatologic conditions in this video:

Reference

Wong, I., Tsuyuki, R. T., Cresswell-Melville, A., Doiron, P., & Drucker, A. M. (2017). Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Canadian pharmacists journal, 150(5), 285–297. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582672/

Asai, Y., Baibergenova, A., Dutil, M., Humphrey,S., etal (2016). Management of acne: Canadian clinical practice guideline. CMAJ February 02,188 (2), 118-126; DOI: https://doi.org/10.1503/cmaj.140665

Groves, M (2016)., Genital Herpes. Am Fam Physician. Jun 1;93(11):928-934. Retrieved from https://www.aafp.org/afp/2016/0601/p928.html

Boivin, G., Jovey, R., Elliott, C. T., & Patrick, D. M. (2010). Management and prevention of herpes zoster: A Canadian perspective. The Canadian journal of infectious diseases & medical microbiology,21(1), 45–52. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852282/

American Heart Association (2019). Kawasaki disease. Retrieved from https://www.heart.org/en/health-topics/kawasaki-disease

Health Link BC (2019). Scarlet fever. Retrieved from https://www.healthlinkbc.ca/health-topics/tv7012spec

Cash, J., Glass, C., (2014). Family practice guidelines. New York: Springer

Browne, A., MacDonald, J., &Luctkar-Flude, M. (2009).Physical examination & health assessment. Illinois Saunders.