text
stringlengths 0
4.03k
| source
stringclasses 1
value |
|---|---|
A. Consult with a physician when steroid treatment is necessary or if worsening symptoms develop despite adequate therapy. Individual Considerations A. Pregnancy: If medications are necessary during pregnancy, consider the gestational age of the fetus and category of medication. B. Pediatrics: For infants and children, consider hydroxyzine (Atarax) 0. 5 mg/kg/dose three times daily as needed for severe pruritus. C. Elderly: Patients may only exhibit scaling as the prominent irritation rather than erythema and inflammation. Topical medications (neomycin, vitamin E, lanolin) and acrylate adhesives are common causes of contact dermatitis. Eczema or Atopic Dermatitis Jill C. Cash and Amy C. Bruggemann Definition A. This pattern of skin inflammation has clinical features of erythema, itching, scaling, lichenification, papules, and vesicles in various combinations. Currently, the term eczema is used interchangeably with dermatitis. Most common variants are atopic dermatitis and atopic eczema. Classification is done by cause, either endogenous or exogenous. Incidence A. Overall prevalence of all forms of eczema is about 18 in 1,000 in the United States. B. With atopic dermatitis, 60% of those affected become afflicted between infancy and 12 years of age. It is more common in boys. Approximately 20% of children and 3% of adults are affected. Pathogenesis A. Eczema is characterized by a lymphohistiocytic infiltration around the upper dermal vessels. Epidermal spongiosis or intercellular epidermal edema and inflammation are seen. 166 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Predisposing Factors A. Family history of atopic triad: Dermatitis, asthma, and allergic rhinitis B. Exposure to allergens 1. Common foods: Cow's milk, nuts, wheat, soy, and fish 2. Common environmental allergens: Dust, mold, cat dander, and low humidity (dry air) C. Exposure to topical medications, most commonly neomycin, lanolin, and topical anesthetics like benzocaine D. Skin irritants: Harsh soaps, skin-care products with perfumes, chemicals and alcohol, fabrics containing wool, tight clothing E. Stress Common Complaints Skin changes A. Itching, impossible to relieve B. Dryness C. Discoloration, lichenification, and scaling D. Skin thickening E. Associated bleeding and oozing skin Other Signs and Symptoms A. Primary lesions, papules, and pustules that may lead to excoriation B. Lesions commonly seen on trunk, face, and antecubital and popliteal fossae of children. Adults will have lesions on the face, trunk, neck, and genital area. C. Other common features include infraorbital fold (Dennie sign), increased palmar creases, facial erythema, and scaling. Subjective Data A. Determine whether the onset was sudden or gradual. B. Ask the patient if the skin is itchy or painful. C. Assess if there is any associated discharge (blood or pus). D. Ask if the patient has recently taken any antibiotics, other oral drugs, or topical medications. E. Ask the patient about use of soaps, creams, or lotions. 167 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Assess for any preceding systemic symptoms (fever, sore throat, anorexia, vaginal discharge). G. Ask the patient about recent travel abroad. H. Rule out insect bites. I. Rule out any possible exposure to industrial or domestic toxins. J. Elicit what precipitates itching. K. Evaluate for increased stress level at home, work, in relationships, and so on. Physical Examination A. Check temperature (if indicated). B. Inspect 1. Inspect skin for lesions. 2. Recognize bacteria-infected eczema; Staphylococcus aureus is the most common pathogen. It appears with acute weeping dermatitis; crusted, and small, superficial pustules. Diagnostic Tests A. Culture skin lesions to determine viral, bacterial, or fungal etiology. B. Blood work: Serum immunoglobulin E (Ig E) is elevated with atopic dermatitis. Differential Diagnoses A. Atopic dermatitis, acute or chronic B. Contact dermatitis, acute or chronic C. Seborrheic dermatitis D. Ichthyosis vulgaris E. Bacterial/fungal infections F. Neoplastic disease G. Immunologic and metabolic disorders Plan A. General interventions 1. Frequently treat the dry skin with emollients (Aquaphor, Eucerin). 2. Pat, do not rub skin. 3. Children: Only bathe every two to three nights. Avoid excessive use of 168 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
soap and water when bathing Use gentle cleansers such as Cetaphil or Cerave when bathing. 4. Avoid wool products and lanolin preparations. 5. Keep fingernails cut short to prevent scratching/scarring skin. 6. May need to treat secondary bacterial infections as appropriate. 7. Eliminate trigger foods one at a time for 1 month at a time to see improvement. Begin with eliminating cow's milk products. Consider soy-based foods instead. 8. Allergy testing may be considered if symptoms continue. 9. Ointments are usually recommended over creams for moisturizing. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eczema. ” C. Pharmaceutical therapy 1. Atopic: Acute, adult a. Wet dressings with Burow's solution and change every 2 to 3 hours b. Potent topical corticosteroid: Betamethasone valerate 0. 1% two to three times daily for up to 2 to 3 weeks c. Antihistamine of choice: Cetirizine Hcl (Zyrtec) or diphenhydramine Hcl (Benadryl) d. Severe cases: Oral steroid: Prednisone 1 mg/kg (40-60 mg/d) tapered over 2 to 3 weeks 2. Atopic: Acute; occurs in infants and children a. Hydrocortisone: Infants and children—2. 5% ointment twice daily; 1% on face and intertriginous areas b. Adolescents: Triamcinolone acetonide 0. 1% (Aristocort) ointment; apply thinly twice daily for 2 to 3 weeks. Precautions should be given regarding possibility of hypopigmentation of skin even with short-term use of steroids on skin. c. Antihistamines for itching i. Infants and children: May use hydroxyzine (Atarax) 0. 5 mg/kg/dose three times daily as needed or diphenhydramine Hcl (Benadryl). For those 2 to 6 years:6. 25 mg every 4 to 6 hours. For those 6 to 12 years: 12. 5 to 25 mg every 4 to 6 hours. ii. Adolescents: May use hydroxyzine 25 to 50 mg/dose every 4 to 6 hours or diphenhydramine Hcl (Benadryl). iii. Atopic: Chronic, adult—short course of potent topical 169 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
corticosteroid betamethasone dipropionate (Diprolene) or clobetasol propionate (temovate) twice daily for 7 days. 3. Antibacterial treatments for secondary bacterial infections: S. aureus a. Adults: i. Augmentin 875 mg by mouth twice a day for 10 to 14 days ii. Keflex 500 mg by mouth four times a day for 10 to 14 days iii. Erythromycin 500 mg by mouth four times a day for 10 to 14 days or iv. Dicloxacillin 250 mg every 6 hours for 10 days b. Children: i. Augmentin 25 to 45 mg/kg/d by mouth in two divided doses for 10 days ii. Erythromycin 30 to 50 mg/kg/d by mouth in two, three, or four evenly divided doses for 10 days iii. Omnicef (cefdinir): Not recommended for children younger than 6 months; 6 to 12 months:7 mg/kg every 12 hours for 10 days Follow-Up A. See patient in office in 1 to 2 weeks and then every month until condition is stabilized. B. Monitor the patient for superimposed staphylococcal infection; may use oral erythromycin or dicloxacillin. C. Patient may be seen every 3 to 6 months thereafter for patient education updates. Consultation/Referral A. Eczema herpeticum (herpes simplex type 1) may progress rapidly. Refer the patient to a dermatologist. B. Refer the patient to a dermatologist if skin eruptions are severe or fail to respond to conservative treatment. Individual Considerations A. Pregnancy: Avoid oral steroids. B. Children: Teach patients to apply emollients when they have an itch rather than scratching. The goal is to control the rash and symptoms. C. Young adults and elderly: Nummular eczema is commonly seen, 170 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
characterized by coin-shaped vesicles and papules seen on extremities and/or trunk. Erythema Multiforme Jill C. Cash and Amy C. Bruggemann Definition A. This dermal and epidermal inflammatory process is characterized by symmetric eruption of erythematous, iris-shaped papules (“target” lesions), and vesiculobullous lesions. Incidence A. Erythema multiforme accounts for up to 1% of dermatology outpatient visits. B. Children younger than 3 years and adults older than 50 years are rarely affected. C. It may occur in seasonal epidemics. D. Approximately 90% of cases of erythema multiforme minor follow a recent outbreak of herpes simplex virus (HSV)-1 or mycoplasma infection. Pathogenesis A. The disorder is thought to be an immunologic reaction in the skin, possibly triggered by circulating immune complexes. Predisposing Factors A. Infections: Recurrent HSV, mycoplasmal infections, and adenoviral infections B. Drugs: Sulfonamides, phenytoin, barbiturates, phenylbutazone, penicillin C. Idiopathic: Greater than 50%; consider occult malignancy Common Complaints A. Rash with intense pruritus B. Nonspecific upper respiratory infection followed by rash C. General malaise, body aches, and joint pain 171 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Fever Other Signs and Symptoms A. Primary: Macules, papules, and plaques B. Secondary: Erythema, dull red target-like lesions blanch to pressure; distribution is symmetric, primarily on flexor surfaces. Classic target lesions develop abruptly and symmetrically and are heaviest peripherally; they often involve palms and soles. C. Swelling of hands and feet D. Painful oral lesions E. Eye discomfort (redness, itching, burning, pain, visual changes) Subjective Data A. Ask if the patient has ever been diagnosed with erythema multiforme. B. Determine whether the onset of symptoms was sudden or gradual. C. Assess for any associated discharge (blood or pus). D. Identify the location of the symptoms. E. Complete a drug history. Has the patient recently taken any antibiotics or other drugs? Question the patient regarding use of any topical medications. F. Determine the presence of any preceding systemic symptoms (fever, sore throat, anorexia, or vaginal discharge). G. Rule out any possible exposure to industrial or domestic toxins. H. Question the patient concerning any possible contact with venereal disease. I. Ask the patient about any close physical contact with others with skin disorders. J. Elicit information concerning any possible exposure to HIV. K. Rule out sources of chronic infection, neoplasia, or connective tissue disease. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Skin for lesions 2. Mouth and mucous membranes for lesions C. Palpate abdomen for masses and tenderness. 172 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Auscultate heart, lungs, and abdomen. E. Neurologic examination Diagnostic Tests A. Punch biopsy of skin B. Complete blood count (CBC) C. Urinalysis Differential Diagnoses A. Erythema multiforme 1. Erythema multiforme minor: Pruritus, swelling of hands and feet, painful oral lesions 2. Erythema multiforme major: Fever, arthralgias, myalgias, cough, oral erosions with severe pain B. Urticaria C. Viral exanthems D. Stevens-Johnson syndrome (SJS): SJS is a severe, life-threatening, systemic reaction with fever, malaise, cough, sore throat, chest pain, vomiting, diarrhea, myalgia, arthralgia, and severe skin manifestations with painful bullous lesions on mucous membranes. E. Pemphigus vulgaris F. Bullous pemphigoid G. Other bullous diseases H. Staphylococcal scalded skin syndrome I. Vasculitis Plan A. General interventions 1. Identify and treat precipitating causes or triggers. 2. Burow's solution or warm compresses may be used for mild cases as needed. 3. Oral lesions may be treated with saline solution, warm salt water, and/or Mary's mouthwash (Benadryl, lidocaine, and Kaopectate). 4. Discontinue any medications suspected of precipitating symptoms. 5. Provide adequate pain relief if skin or oral lesions are painful. Lesions remain fixed at least 7 days. 173 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
6. Maintain nutrition and fluid replacement for this hypercatabolic state. 7. Consider chronic viral suppression therapy for recurrent herpes simplex viral infections. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Erythema Multiforme. ” C. Pharmaceutical therapy 1. Antihistamines, such as Benadryl or Claritin, may be used for itching. 2. Acetaminophen may be used to reduce fever and for general discomfort/pain. 3. Potent topical corticosteroids: Betamethasone dipropionate 0. 05% or clobetasol propionate 0. 05% twice daily for up to 2 weeks. Avoid use on face and groin. 4. Open lesions should be treated like open burn wounds. Stop offending medications that may cause blistering of wounds and treat with steroids. 5. Oral antibiotics may be needed to control secondary bacterial skin infection. 6. Hospitalization for severe cases. Intravenous immunoglobulins may be needed. Follow-Up A. See the patient in the office in 1 to 2 days to evaluate initial treatment. Consultation/Referral A. If the patient has recurrent or chronic infection, refer him or her to a physician. B. Immediate consultation and/or hospital admission is critical if SJS is suspected. Individual Consideration A. Pediatrics: Systemic corticosteroids may increase the risk of infection and prolong healing. Use low-to mid-potency topical corticosteroids. Folliculitis Jill C. Cash and Amy C. Bruggemann 174 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Definition A. Folliculitis is a bacterial infection of the hair follicle. B. Malassezia folliculitis, also known as pityrosporum, is an inflammatory skin disorder of the hair follicle triggered by yeast. This is often confused with acne vulgaris; the defining difference is itch. Incidence A. A very common disorder, folliculitis occurs in all ages and is seen more frequently in males. B. Malassezia folliculitis is commonly seen in patients with immunosuppression, diabetes, and antibiotic use. Pathogenesis A. Bacterial organisms (most commonly Staphylococcus aureus) invade the follicle wall and cause an infectious process. B. For malassezia folliculitis, fungal organisms invade the follicle walls and cause a fungal infection that causes a pruritic rash. Predisposing Factors A. Break in the skin tissue B. Use of razors on skin C. Poor hygiene D. Diabetes Common Complaint A. Outbreak of pustules on the face, scalp, or extremities that do not resolve despite proper hygiene and care. Other Signs and Symptoms A. Tenderness and itching at the site B. Furuncle (abscess): A deep pustule, tender, firm or fluctuant, found in groin, axilla, waistline, or buttocks C. Carbuncle: A group of follicles coalescing into one larger, painful, infected area; fever and chills possible. D. Excoriated folliculitis: Chronic thickened, excoriated papules or nodules 175 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Subjective Data A. Elicit the initial outbreak of lesions and onset and progression of lesions. B. Identify what makes the lesions better or worse. C. Ask the patient what medications, soaps, or lotions have been used on the lesions. D. Complete a medical history. Ask if the patient has had an outbreak similar to this before. E. Describe systemic symptoms if they have occurred (fever, chills, etc. ). F. Does the patient have a beard, shave his face, or use a razor frequently? G. Is there a recent history of use of a hot tub? (Commonly seen 1-4 days after use of hot tub, whirlpool, or swimming pool. ) H. Does the patient wear tight pants/jeans or use oils that clog pores in the groin area? I. Is the patient currently being treated with antibiotics for acne? (May see flare of gram-negative folliculitis with chronic use of antibiotics. ) Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect: Assess skin for lesions and describe. C. Palpate: Palpate lesions and associated lymph nodes. Diagnostic Tests A. Culture and sensitivity to verify appropriate antibiotic coverage B. Gram stain C. Potassium hydroxide (KOH)/wet prep D. Fungal culture hair if fungi suspected (tinea of scalp) E. Skin biopsy for the diagnosis of malassezia folliculitis Differential Diagnoses A. Folliculitis B. Acne vulgaris C. Ingrown hair follicle D. Keratosis pilaris E. Contact dermatitis Plan 176 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. General interventions 1. Apply warm, moist compresses to site for comfort. B. Patient teaching: 1. See Section III: Patient Teaching Guide for this chapter, “Folliculitis. ” 2. If razors are used on the area, have the patient use clean, sharp razors, throw old razors away, and not share razors. Avoid use of irritating creams or lotions on affected area. 3. Encourage proper hygiene, with frequent washing of hands and skin with an antibacterial soap. 4. Warm compresses three to four times a day are encouraged at the site for 15 to 20 minutes. 5. Bleach bath (0. 5-1 cup of bleach to 20 L water) reduces spread of Staphylococcus infection. C. Pharmaceutical therapy 1. Mild cases: Apply mupirocin (Bactroban) ointment to affected area three times daily until resolved. 2. S. aureus a. Dicloxacillin (Dynapen) 250 mg by mouth four times daily for 10 to 14 days b. Erythromycin 250 mg by mouth four times daily for 10 to 14 days c. Cephalexin (Keflex) 500 mg by mouth for 10 to 14 days 3. Pseudomonas aeruginosa a. Ciprofloxacin (Cipro) 500 mg by mouth twice daily for 10 days b. Ofloxacin 400 mg by mouth twice daily for 10 days 4. Antistaphylococcal antibiotics a. Cephalexin 250 to 500 mg four times a day (children:25-50 mg/kg/d given in two divided doses) b. Clindamycin 150 to 300 mg four times a day (children:8-16 mg/kg/d in three to four doses/d) c. Dicloxacillin 125 to 500 mg four times a day (children:12. 5 mg/kg/d four times a day) d. Erythromycin 250 to 500 mg four times a day (children:30-50 mg/kg/d four times a day) 5. Bacterial infections caused by organisms other than Staphylococcus may be treated for an extended period, 4 to 8 weeks. These areas may 177 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
include axilla, chest, back, beard, and groin. 6. Methicillin-resistant Staphylococcus aureus (MRSA) a. Bactrim DS 160/800 twice a day (children: 8-10 mg/kg/d divide and give q12h) b. Doxycycline 100 mg twice daily for 1 day and then once a day for the remainder of the duration (children: 2. 2 mg/kg twice daily for 1 day and then for the remainder of the duration once a day) 7. Severe cases may be treated with oral antibiotics with topical permethrin every 12 hours every other night for a 6-week period or itraconazole 400 mg daily, isotretinoin 0. 5 mg/kg/d for up to 4 to 5 months with ultraviolet B (UVB) light therapy. Consider dermatology referral for severe cases. 8. Treatment for malessezia folliculitis is as follows: a. Antifungal treatment: Oral antifungal medications (itraconazole, fluconazole, or ketoconazole) should be prescribed for at least 4 weeks for treatment (Rubenstein & Malerich, 2014). Follow-Up A. If not resolved in 2 weeks, further evaluation is needed. B. Severe cases, in which carbuncles are not improved with antibiotic therapy, warrant incision and drainage and referral to dermatology. C. Continue to follow every 2 weeks until resolved. D. Test for diabetes mellitus in severe cases. Consultation/Referral A. Refer the patient to a physician for testing for immunodeficiency if severe cases occur or if resistance is seen. B. Dermatology referral. Hand, Foot, and Mouth Syndrome Jill C. Cash and Amy C. Bruggemann Definition A. This is a viral infection caused by coxsackievirus A16, with vesicular 178 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
lesions present on the hands, feet, and oral mucosa. Incidence A. Hand, foot, and mouth syndrome is most commonly seen in preschool children. Pathogenesis A. Enteroviruses invade the intestinal tract of humans and are spread to others by fecal-oral and/or oral-oral (respiratory) routes. The incubation period is approximately 4 to 6 days. Predisposing Factors A. Childhood B. Confined households or day care centers, camps C. Seasonal: Summer and fall most common Common Complaints A. Generalized rash, with lesions on the tongue, gums, and roof of the mouth B. Lesions (vesicles) also present on the hands, feet, and buttocks Other Signs and Symptoms A. Fever B. Sore throat C. Some enteroviruses have been associated with severe consequences such as meningitis, encephalitis, and others. The family should monitor symptoms carefully. Subjective Data A. Question the patient regarding onset, duration, and progression of symptoms and lesions. B. Determine whether any family member or other contact person had similar symptoms. C. Identify areas where the child comes in contact with numerous children (child care facility, nurseries at church, school, etc. ). D. If not noted in the presenting symptoms, ask the patient about his or her upper respiratory symptoms (sore throat, fever, headache, runny nose, cough, 179 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
etc. ). Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect skin, ears, nose, and oral cavity for lesions. C. Palpate 1. Palpate abdomen and lymph nodes in neck. 2. Assess for meningism. D. Auscultate lungs and heart. Diagnostic Test A. Usually none; consider cultures of oral lesions if secondary bacterial infection is suspected. Differential Diagnoses A. Hand, foot, and mouth syndrome B. Pharyngitis C. Pneumonia D. Meningitis E. Meningococcemia: Exanthem, petechial rash Plan A. General interventions: Supportive treatment—warm saline gargles, acetaminophen (Tylenol) as needed for discomfort, and increased fluids. Popsicles are useful to soothe oral lesions, especially for small children. B. Patient teaching: Reinforce good oral and body hygiene. The virus may be harbored in the gastrointestinal tract for long periods. C. Pharmaceutical therapy 1. None is recommended. 2. Acetaminophen (Tylenol) as needed for fever and malaise. Follow-Up A. None is recommended unless symptoms worsen or do not resolve in 7 to 10 days. Consultation/Referral 180 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Refer to physician for any symptoms related to meningitis or encephalitis. Individual Consideration A. Pediatrics: Seen primarily in the pediatric population Herpes Simplex Virus Type 1 Jill C. Cash and Amy C. Bruggemann Definition Herpes simplex virus (HSV)-1 viral infection of the cutaneous tissue manifests itself by vesicular lesions on the mucous membranes and skin. HSV-1 is most often associated with oral lesions (mouth and lips), and HSV-2 is associated with genital lesions. The virus appears in three stages: A. Primary B. Latent C. Recurrent infections Incidence A. HSV-1 is seen in patients of all ages and in equal numbers of males and females. B. There are approximately 776,000 new cases of herpes diagnosed annually in the United States. Pathogenesis A. Viral infection can be transmitted from a vesicular lesion or fluid (saliva) containing the virus to the skin or mucosa of another person by direct contact, with an incubation period of 2 to 14 days. Trigeminal ganglia are the host of the oral virus. The virus can be reactivated, whereupon it travels along the affected nerve route and produces recurrent lesions. Common sites of infection are the lips, face, buccal mucosa, and throat. Predisposing Factors A. Immunocompromised patients B. Prior HSV infections 181 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Exposure to virus Common Complaint A. Painful lips, gums, and oral mucosa Other Signs and Symptoms A. Primary lesion: Fever, blisters on lips, malaise, and tender gums B. Recurrent episodes: Fever blisters with prodrome of itching, burning, and tingling sensation at the site before vesicles appear Subjective Data A. Ask questions regarding location, onset, and duration of lesions. B. Elicit description of prodromal symptoms. C. Ask the patient if systemic symptoms occur with vesicular outbreak. D. Determine when the initial outbreak of lesions occurred (commonly seen in childhood). E. Inquire whether the patient has been exposed to anyone with similar lesions. F. If the lesion(s) is recurrent, ask the patient if stress, skin trauma, or sun exposure stimulates an outbreak of fever blisters. Physical Examination A. Inspect the skin and note location, appearance, and stage of vesicles. B. Palpate lymph nodes for lymphadenopathy. Diagnostic Test A. Viral cultures Differential Diagnoses A. HSV-1 B. Impetigo: Appears as amber-colored vesicular lesions with crusting. C. Stomatitis: Appears as erythemic or erosion lesions in the mouth and lips. D. Herpes zoster: Causes vesicles that run along a single dermatome. E. Stevens-Johnson syndrome (SJS) F. Herpangina: Vesicles can be noted on the soft palate, tonsillary area, and uvula area; usually caused by the coxsackievirus. 182 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Plan A. General interventions 1. Comfort measures. Ice may be used to reduce swelling as needed. 2. Vaseline or other lip ointments may be applied as needed and lip ointment with sun protection factor (SPF)-30 or greater may be applied when exposed to sunlight. B. Patient teaching 1. Educate the patient regarding the disease process of HSV-1. 2. Instruct the patient to wash hands frequently. 3. Suggest proper care of lips to prevent drying and to reduce pain. 4. Educate regarding transmission of virus to others. 5. Teach the patient to expect recurrences at variable times. C. Pharmaceutical therapy: Precautions should be used when administering medication to patients who are immunocompromised and who have a history of renal insufficiency. 1. Lidocaine 2% as needed for comfort. 2. Diphenhydramine (Benadryl) elixir may be used to rinse mouth as needed. 3. Acetaminophen (Tylenol) as needed for pain. 4. Campho-Phenique application as needed. 5. Initial episode: Acyclovir 200 mg by mouth five times per day for 7 to 10 days or until resolved. 6. Recurrent episodes: Begin one of the following when prodrome begins or within 2 days of onset of lesions to get maximum effect a. Acyclovir 200 mg by mouth five times per day for 5 days b. Acyclovir 800 mg by mouth twice daily for 5 days 7. Other alternative antivirals: Dosage depends on renal function a. Famciclovir (Famvir) b. Valacyclovir (Valtrex) 8. Suppressive therapy a. Acyclovir 200 mg by mouth two to five times per day for 1 year b. Acyclovir 400 mg by mouth twice daily for 1 year Follow-Up A. None needed if resolved without complications 183 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Consultation/Referral A. Refer the patient to a physician if treatment is unsuccessful or further complications arise. Individual Considerations A. Pediatrics 1. Initial outbreak commonly occurs in childhood. B. Adolescents/adults 1. HSV-1 can also be transmitted sexually when having oral sex. Educate teens/adults regarding transmitting the virus during sexual contact. Transmission is possible if having sexual relations with partners; avoid contact when lesions are present. 2. Advise using a dental dam during oral sex to prevent transmission. 3. Avoid sharing toothbrushes and eating utensils. Herpes Zoster or Shingles Jill C. Cash and Amy C. Bruggemann Definition A. Herpes zoster is a viral infection manifested by painful, vesicular lesions on the skin, limited to one side of the body, following one body dermatome. Incidence A. Infection may occur at any age; however, it is more common in older adults and the elderly. It occurs in 10% to 20% of the U. S. population. Pathogenesis A. After the primary episode of chickenpox (varicella zoster), the virus remains dormant in the body. Herpes zoster occurs when the varicella virus has been stimulated and reactivated in the dorsal root ganglia, producing the clinical manifestations of herpes zoster as discussed in the following. Duration of infection usually lasts 14 to 21 days, but may be longer in elderly or debilitated patients. 184 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Predisposing Factors A. Adulthood B. Immunocompromised patients C. Spinal cord trauma or injury Common Complaints A. Prodrome: Itching, burning, tingling, or painful sensation at lesion sites B. Active: Malaise, fever, headache, or pruritic rash on the skin Other Signs and Symptoms A. Lesions: Clusters of vesicles on an erythemic base that burst and produce crusted lesions. These are most commonly found on the chest and back area, but they may also occur on the head and neck area or extremities. Distribution of lesions typically appears along a single dermatome. B. Motor weakness (may be seen in approximately 5% of patients) Subjective Data A. Determine onset, location, and progression of rash. B. Ask the patient about prodromal symptoms: Burning, itching, tingling, or painful sensation at the site before lesions break out. C. Evaluate patient status regarding immunosuppressive agents, diseases, and so forth. Physical Examination A. Check temperature, pulse, respiration, and blood pressure. B. Inspect 1. Observe skin for lesions, noting characteristics and distribution. 2. Inspect ears, nose, and throat. C. Auscultate heart and lungs. Diagnostic Tests A. Usually none B. Culture vesicular lesions C. Consider Tzanck smear D. Young patients with herpes zoster: Consider test for HIV 185 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Differential Diagnoses A. Herpes zoster B. Varicella C. Poison ivy D. Herpes simplex virus (HSV) E. Contact dermatitis F. Coxsackievirus G. Postherpetic neuralgia Plan A. General interventions 1. Comfort measures. Instruct the patient to apply wet dressings (Burow's solution) on the site for 30 to 60 minutes at least four times a day. Calamine lotions may be used as needed; oatmeal (Aveeno) bath may be used for comfort; acetaminophen (Tylenol) is taken as needed for malaise, temperature, and comfort. B. Patient teaching: 1. See Section III: Patient Teaching Guide for this chapter, “ Herpes Zoster, or Shingles. ” 2. Tell the patient that the rash usually lasts approximately 2 to 3 weeks. 3. Instruct the patient to monitor for signs/symptoms of postherpetic neuralgia. 4. Instruct the patient to call if symptoms worsen or do not improve, or signs of bacterial infection occur. 5. Emphasize to the patient that the virus is easily transmitted to vulnerable persons. C. Pharmaceutical therapy 1. Antiviral medications should be initiated within 24 to 48 hours after outbreak. a. Acyclovir (Zovirax) 800 mg every 4 hours while awake for 7 to 10 days b. Famciclovir (Famvir) 500 to 750 mg by mouth three times daily for 7 days c. Valacyclovir (Valtrex) 1,000 mg by mouth three times daily for 7 days 186 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Acetaminophen (Tylenol) or ibuprofen as needed for pain or discomfort. 3. Narcotics may be used for severe pain as needed. 4. Postherpetic neuralgia a. Postherpetic neuralgia may be treated with narcotics or other pain-relieving medications. b. Long-term medications may be needed for control of pain. i. Gabapentin 100 to 600 mg three times daily ii. Amitriptyline 25 mg every bedtime or other low-dose tricyclic antidepressants iii. Lyrica: Start 150 mg/d orally (PO) divided twice (BID) a day to three times a day (TID), may be increased to 300 mg/d PO divided BID-TID within 1 week, and then may be increased to 600 mg/d PO divided BID-TID after another 2 to 4 weeks; maximum 600 mg/d; taper dose over at least 1 week to discontinue medication. 5. If secondary bacterial infection of the skin occurs, apply silver sulfadiazine (Silvadene) topically to the site until resolved. 6. Use of steroids is controversial. Corticosteroids may be used with caution. May increase risk of dissemination. Follow-Up A. As needed for complications. B. Monitor the patient for complications: Postherpetic neuralgia, Guillain-Barré syndrome, motor weakness, secondary infection, meningoencephalitis, ophthalmic and facial palsy, corneal ulceration, and so forth. Consultation/Referral A. Ramsay Hunt syndrome occurs when a shingles outbreak affects the facial nerve near one of the ears. This can cause facial paralysis and hearing loss in the affected ear. Consult a physician. B. Hutchinson's sign refers to vesicles in the peri-orbital region. These patients require an ophthamologist referral. C. Consult with a physician if secondary infection occurs or if secondary complications arise. 187 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Individual Considerations A. Pregnancy: Acyclovir falls under category C drug classification. The safety and efficacy of the use of the antiviral medications during pregnancy need to be considered. B. Pediatrics: Shingles is rarely seen in children. C. Elderly 1. Postherpetic neuralgia occurs in approximately 15% of patients. It is commonly seen in elderly patients. 2. The Centers for Disease Control and Prevention (CDC) recommends the shingles vaccine Zostavax for all patients 60 years of age and older, irrespective of whether they have had the chickenpox or shingles infection in the past. For those who have had a recent shingles outbreak, it is recommended that resolution of the rash be complete before administering the Zostavax vaccination. 3. The virus is contagious for those who have not had chickenpox. Impetigo Jill C. Cash and Amy C. Bruggemann Definition A. Impetigo is a bacterial infection of the skin, most commonly caused by Staphylococcus aureus or Streptococcus pyogenes, or both. Incidence A. It occurs equally in males and females and is most commonly seen in children, especially those 2 to 5 years of age. Pathogenesis A. An alteration in the skin integrity allows bacterial invasion into the epidermis, causing an infection. Small, moist vesicles ranging from red macules to honey-colored crusts or erosions occur singly or grouped together. Most common organisms are S. aureus and Group A beta-hemolytic S. pyogenes. 188 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Predisposing Factors A. Poor hygiene B. Warm climate C. Break in the skin Common Complaint A. Tender sores around the mouth and nose area in which the lesions continue to spread and worsen, despite over-the-counter (OTC) medication treatment. Subjective Data A. Elicit onset, progression, duration, and location of lesions. B. Ask the patient whether he or she has had contact with any other child or person with similar lesions. C. Assess whether the patient exhibits any other symptoms, especially systemic symptoms (fever, malaise, etc. ). D. Elicit what treatment has been tried, if any. Physical Examination A. Check temperature. B. Inspect 1. Examine skin, noting types of lesions and skin involvement. 2. Examine ears, nose, mouth, and throat. C. Auscultate lungs and heart. Diagnostic Tests A. None required B. May perform culture if recurrent or resistant to treatment Differential Diagnoses A. Impetigo B. Varicella C. Folliculitis D. Erysipelas E. Herpes simplex 189 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Second-degree burns G. Pharyngitis or tonsillitis: Throat erythema, with tonsillary hypertrophy and exudate present; lymph nodes: Adenopathy of anterior cervical chain H. Ecthyma: Severe case of impetigo with lymphadenitis I. Insect bites J. Necrotizing fasciitis K. Contact dermatitis L. Scabies Plan A. General interventions 1. Crusted lesions may be removed with thorough, gentle washing with mild soap three to four times daily. 2. Impetigo must be adequately treated and resolved to prevent postinfection complications such as the following: Poststreptococcal acute glomerulonephritis, cellulitis, ecthyma, and bacteremia. B. Patient teaching: Encourage good handwashing and hygiene to reduce spreading infection. C. Pharmaceutical therapy 1. If few lesions are noted without involvement of face or cellulitis: Mupirocin (Bactroban) ointment—to site four times daily for 10 days 2. Systemic antibiotics a. Children older than 3 months: Amoxicillin/clavulanate 40 mg/kg/d divided every 12 hours b. Adults: Amoxicillin/clavulanate 875/125 mg every 12 hours c. Children: Cephalexin 30 mg/kg/d po divided every 12 hours d. Adults: Cephalexin 500 mg every 12 hours 3. Other effective antibiotics include cefaclor, cephradine, cefadroxil, clindamycin, and amoxicillin. Follow-Up A. Schedule appointment in 10 to 14 days to determine resolution of infection. Consultation/Referral A. Consult a physician if complications arise or if resolution is not complete 190 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
with antibiotic therapy. Insect Bites and Stings Jill C. Cash and Amy C. Bruggemann Definition A. Bites and/or stings on the skin come from commonly encountered insects: Bees, hornets, wasps, mosquitoes, chiggers, ticks, fleas, fire ants, and bedbugs Incidence A. Bites are seen in all age groups, more common in summer months. Pathogenesis A. Some bites elicit local tissue inflammation and destruction because of proteins and enzymes in the poison or venom of the insect. B. Immunoglobulin E (Ig E)-mediated allergic reactions (immediate or delayed) may occur. C. Serum-sickness reaction may appear 10 to 14 days after a sting with venom. Toxic reactions can also occur from multiple stings yielding large inoculation of poison or venom. D. With tick bites, exposure to Rocky Mountain spotted fever, Lyme disease, ehrlichiosis, and babesiosis disease may occur. Predisposing Factors A. Exposure to areas of heavy insect infestations B. Warm-weather months C. Outdoor exposure with barefeet, bright clothes D. Use of perfumes and/or colognes E. Previous sensitization Common Complaints A. Local reaction: Pain, swelling, and redness at the site after insect bite B. Toxic reaction: Local reaction plus headache, vertigo, gastrointestinal 191 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
symptoms (nausea, vomiting, diarrhea), syncope, convulsions, and/or fever Subjective Data A. Did the patient see what bit or stung him or her? B. If the patient felt the bite or sting, was he or she bitten or stung once or multiple times? C. How long ago did it occur? D. Where was the patient when the injury occurred (environment)? E. Has the patient ever been bitten or stung before? If so, did he or she have any reaction then? If so, what was the treatment? Physical Examination A. Check temperature, pulse, respiration, and blood pressure. Observe overall respiratory status. B. Inspect 1. Inspect site of injury for local reaction; note erythema, rash, or edema. 2. Perform ear, nose, and throat examination. C. Auscultate: Assess heart and lungs. D. Palpate 1. Palpate injured site. 2. Assess nodes for lymphadenopathy. 3. Perform abdominal examination, if appropriate. Diagnostic Tests A. None is required. B. Consider taking skin scrapings to evaluate under a microscope. C. Consider culture if infection is suspected. Differential Diagnoses A. Insect bite 1. Bees, hornets, wasps, bedbugs: Local pain, redness, pruritus, and swelling occur at the site. Red papules and wheals appear, enlarge, and then subside within hours. Delayed hypersensitivity occurs within 7 days with enlarged, local reaction, with fever, malaise, headache, arthralgias, and lymphadenopathy. Toxicity can occur. Anaphylaxis may be seen with generalized warmth and urticaria, erythema, angioedema, intestinal 192 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
cramping, bronchospasm, laryngospasm, shock, and collapse. 2. Ticks: Local redness, swelling, itching; Enlarged area of redness and swelling may occur. 3. Mosquitoes and chiggers: Local redness, swelling, and itching occur. Delayed reaction can include edema and burning sensation. 4. Fleas: Local redness, swelling, and itching occur. Usually papules noted in a zigzag pattern, especially on legs and waist. Note hemorrhagic puncta surrounded by erythematous and urticarial patches. 5. Body lice: Small noninflammatory red spots, intensely pruritic, are found on waist, shoulders, axilla, and neck. Note linear scratch marks. Note secondary infection. 6. Scabies: Pruritus is the dominant symptom. Note inflammation and burrows in skin with papules and vesicles, especially in the webs of the hands and feet. 7. Fire ants: Papules appear and turn to pustules within 6 to 24 hours after bite. Watch for localized necrosis with scarring. Urticaria and angioedema can occur. B. Allergic reaction Plan A. General interventions. Anaphylaxis: Activate emergency medical services (EMS) immediately. 1. With all bites and stings, treat anaphylaxis first. 2. Local reactions: Treat with analgesic of choice. Apply ice packs to the site for approximately 10 minutes. Elevate affected extremities. 3. Delayed reactions: Administer antihistamines as needed. Consider corticosteroid use. 4. Routine wound care: Cleanse wound. Remove stinger. If it is a painful sting, apply a cotton ball soaked in meat tenderizer or sodium bicarbonate paste. 5. Debride as necessary. 6. For embedded insects, apply petroleum jelly, nail polish, or alcohol over site for 30 minutes and wait for insect or tick to withdraw. 7. Referral to allergist-immunologist is recommended for patients with a severe systemic reaction for skin testing and to evaluate for candidacy of venom immunotherapy treatment. 193 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
8. Hospitalize the patient for severe reactions. B. See Section III: Patient Teaching Guide for this chapter, “ Insect Bites and Stings. ” C. Pharmaceutical therapy 1. Antihistamines a. Children i. Younger child:2 to 6 years: Diphenhydramine 6. 25 mg every 4 to 6 hours ii. Older child:6 to 12 years: Diphenhydramine 12. 5 to 25 mg every 4 to 6 hours b. Adult: Diphenhydramine (Benadryl) 50 mg every 6 hours as needed 2. Mild anaphylaxis a. Epinephrine 1:1,000 (aqueous) administered subcutaneously. Usual dose is as follows: i. Children:0. 01 mg/kg; may repeat in 4 hours if needed ii. Adults:0. 3 mg intramuscular (IM); may repeat if needed 3. Oral antihistamines for next 24 hours (Atarax) a. Children: Hydroxyzine hydrochloride (Atarax) 2 to 4 mg/kg/d divided into three doses b. Adults: Hydroxyzine hydrochloride (Atarax) 10 to 25 mg four times daily 4. Severe anaphylaxis a. Epinephrine 1:1,000 (aqueous), given subcutaneously (see mild anaphylaxis, mentioned earlier) b. Oxygen 2 to 4 L as needed c. Albuterol (Ventolin) 5 mg/m L per dose by nebulizer i. Children:0. 1 to 0. 15 mg/kg in 2 m L of saline ii. Adults:2. 5 mg (0. 5 m L of 0. 5% solution) in 2 m L saline 5. Self-treatment for anaphylaxis (emergency treatment kits) a. Ana-Kit contains a preloaded syringe. b. Epipen and Epipen Junior Auto-Injectors are spring-loaded automatic injectors. Children:0. 01 mg/kg IM in thigh. Adults:0. 3 mg IM in thigh. Follow-Up 194 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Follow up in 2 weeks to evaluate effectiveness of treatment. If symptoms worsen before this, reevaluation is needed. Consultation/Referral A. Consult with a physician when anaphylaxis occurs. Individual Considerations A. Pediatrics: Children are at a higher risk than adults for complications of a reaction. B. Geriatrics: Elderly adults are at high risk for complications of reactions. Lice (Pediculosis) Jill C. Cash and Amy C. Bruggemann Definition Pediculosis (lice) is an infestation of the louse on human beings in one of three areas: A. Head (Pediculosis capitis) B. Pubic area (Pthirus pubis) C. Body (Pediculosis corporis) Incidence A. Pediculosis capitis is most common in children. It is estimated that head lice infestations occur in the school systems anywhere from 10% to 40% of the time. B. They are more commonly found in girls than boys. C. Phthirus pubis infestation is more common in adults. D. Lice affect all demographics; all social, racial, and economic groups get lice. Pathogenesis A. Head and body lice are transmitted by direct contact from person to person, that is, through sharing hats, combs, brushes, and so forth. The parasite hatches from an egg, or nit. Once hatched, the lice live on humans by 195 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
sucking blood through the skin. The average adult louse lives 9 to 10 days. The nits appear as small white eggs on the hair shaft. Nits are very difficult to remove and survive up to 3 weeks after removal from the host. Body lice lay nits in the seams of clothing. B. Pubic lice are found at the base of the hair shaft, where they lay nits. Pubic lice are transmitted through sexual contact. Predisposing Factors A. Head and body lice: Exposure to crowded public areas, such as schools; inability to clean and launder clothing, bed linens, and so forth B. Pubic lice: Sexual contact with infected people C. Poor hygiene Common Complaints A. Head lice: Severe itching and scratching of the head, neck area, and commonly behind the ears B. Body lice: Severe itching on the body, which may lead to secondary infections of the skin C. Pubic lice: Severe itching of genital area Other Signs and Symptoms A. Excoriated skin from intense scratching. B. Visible lice or nits in hair, body, or clothing. C. Papules with an erythemic base may develop on the genital area, axilla, chest, beard, or eyelashes. D. Phthirus pubis or nits or lice are found on eyelashes of children. Subjective Data A. Inquire as to exposure to anyone known to have lice. B. Identify whether the patient attends a crowded environment such as school, day care, and so forth. C. Ask if lice and nits have been seen by the patient or guardian. D. Determine onset, duration, and course of symptoms. Ask: When were lice or nits first discovered? E. Assess whether the patient has been symptomatic (itching, scratching). F. Inquire about social habits of cleaning, laundry, and so forth. 196 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Check temperature to rule out any secondary infection. B. Inspect 1. Inspect hair, body, pubic area, and clothing seams for nits or lice. 2. Note excoriation of skin. 3. Examine eyelashes of children. 4. Examine skin for secondary bacterial infection. Diagnostic Tests A. None B. Culture excoriated area if secondary bacterial infection suspected Differential Diagnoses A. Lice B. Scabies Plan A. General interventions 1. Treat immediately with appropriate pediculicides (see Pharmaceutical therapy, in the following). 2. After treatment, it is imperative to remove each nit and louse; use fine-tooth comb for nit removal. 3. Evaluate entire family for lice. 4. Treat secondary bacterial infection as needed. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Lice (Pediculosis). ” 2. Specific instructions need to be given to clients on how to get rid of lice and nits. 3. Reinforce good hygiene; teach children not to share combs, brushes, hats, and hair accessories. C. Pharmaceutical therapy 1. Malathion lotion 0. 5% (Ovide): Pediculicidal and partially ovicidal 2. Permethrin lotion 1% (Nix): Pediculicidal only. Available over the counter (OTC) for treatment. 197 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Synergized pyrethrins (Rid 0. 3%; Available OTC). 4. Apply, repeat in 24 hours, and then again in 1 week. 5. Do not use a shampoo/conditioner or conditioner before using head lice treatments. Do not wash hair for 1 to 2 days after using lice treatment regimen. 6. Pthirus pubis: Lindane (Kwell) or permethrin (Nix); apply to pubic area as directed. 7. Lindane (Kwell) toxicity may occur from ingestion or overuse and is exhibited by headaches, dizziness, and convulsions. 8. Eyelash manifestation: After removing nits, apply petroleum jelly to lashes three to four times a day for 8 to 10 days. Eyelashes should never be treated with pediculicides. Follow-Up A. None recommended B. Some schools and institutions require follow-up to evaluate whether infestation is resolved before admitting the child back into the classroom. Consultation/Referral A. If lice are a repeated problem, contact social services or the health department to have a visiting nurse or aide visit the home to evaluate home conditions and to teach the family how to prevent infestations. Individual Considerations A. Pregnancy: Lindane (Kwell) is contraindicated during pregnancy. B. Pediatrics 198 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Head lice is commonly seen in school-aged children. 2. Lindane (Kwell) should not be used in infants. The American Academy of Pediatrics does not recommend lindane as a first-line treatment for head lice for children secondary to the toxic effects of the brain and central nervous system (CNS). Lichen Planus Jill C. Cash and Amy C. Bruggemann Definition A. Lichen planus is a relatively common acute or chronic inflammatory dermatosis. It affects skin and mucous membranes with characteristic flat-topped, shiny, violaceous (purplish color) pruritic papules with lacy lines on the skin, and milky-white papules in the mouth. Incidence A. Lichen planus accounts for 0. 1% to 1. 2% of office visits to dermatologists. B. It exhibits no racial preference. Pathogenesis A. Etiology is unknown, although it is possibly a cell-mediated immune response. Most cases remit within 7 years. Lesions may heal with significant post-inflammatory hyperpigmentation. Predisposing Factors A. Severe emotional stress B. Drugs may induce lichenoid plaques. Common Complaints A. Rash with or without pruritus B. Primary lesions: Small, flat-topped papules that are polygonal, lightly scaly, and violaceous. C. Secondary lesions: Erythema, scales, and erosions 199 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Other Signs and Symptoms A. Distribution: Volar aspect of wrists, ankles, mouth, genitalia, and lumbar region B. Wickham's striae (white, lacelike pattern on surface) C. Scalp: Atrophic skin with alopecia D. Nails: Destruction of nail fold and bed, especially in the large toe E. Men: Lesions of glans penis F. Women: Erosive lesions of labia and vulva Subjective Data A. Determine whether the onset was sudden or gradual. B. Ask the patient to describe if the skin is itchy or painful. C. Assess lesions for any associated discharge (blood or pus). D. Identify the location(s) of the problem. E. Complete a drug history. Ask the patient if he or she has recently taken any antibiotics or other drugs. Ask if he or she has used any topical medications, lotions, or other creams. F. Determine the presence of any preceding systemic symptoms (fever, sore throat, anorexia, or vaginal discharge). G. Rule out insect bites. H. Identify any possible exposure to industrial toxins, domestic toxins, or color-film-developing chemicals. I. Ask if the patient has had any possible sexual contact with persons with HIV or sexually transmitted infections (STIs). J. Ask if the patient has had close physical contact with others with skin disorders. Physical Examination A. Inspect 1. Inspect skin and note lesion distribution. 2. Inspect mucous membranes: Buccal mucosa, tongue, and lips. 3. Examine hair and nails. 4. Observe genitalia. Diagnostic Tests 200 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. A drop of mineral oil accentuates the papule B. If necessary to confirm diagnosis, deep shave or punch biopsy of developed lesions C. HIV or STI testing if indicated D. Hepatitis testing should be completed to assess for hepatitis C as lichen planus has been shown to have a correlation. Differential Diagnoses A. Lichen planus B. Lichenoid drug eruptions C. Leukoplakia D. Chronic graft-versus-host disease E. Candidiasis (thrush) F. Lupus erythematosus G. Contact dermatitis H. Bite trauma I. Secondary syphilis Plan A. General interventions: Discontinue any suspected drug agent. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Lichen Planus. ” 1. Instruct patients that the disease may be chronic; most cases resolve spontaneously. 2. Encourage the patient to avoid severe emotional stress. 3. Encourage the patient to avoid scratching and prevent secondary infection. 4. Reassure the patient that lichen planus is not contagious. C. Pharmaceutical therapy 1. Oral antihistamines: Hydroxyzine hydrochloride 10 to 50 mg four times daily as needed for pruritus, or cetirizine Hcl (Zyrtec) 10 mg daily 2. Medium-to high-potency topical corticosteroids a. Mouth lesions: Fluocinonide 0. 05%, ointment or gel, two or three times daily b. Body lesions: Betamethasone dipropionate (Diprolene) 0. 05%, triamcinolone (Kenalog), clobetasol (Temovate, Cormax) 0. 05%, or 201 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
other class 1 cream or ointment, two times daily for 2 to 3 weeks and then stop use. Caution patients about steroid atrophy. c. Genital lesions: Desonide cream 0. 05% twice daily initially, although higher potency creams may be necessary. Topical corticosteroids should be used on genitalia in short bursts only. d. Hypertrophic lesions: Intralesional injections, such as injecting triamcinolone 5 to 10 mg/m L, 0. 5 to 1 m L per 2-cm lesion, are helpful for pruritus relief. Use cautiously in dark-skinned patients because of risk of hypopigmentation. 3. Oral prednisone is rarely used, but if necessary use with a short course only and taper. Follow-Up A. See the patient in 1 week for evaluation of treatment. Consultation/Referral A. Refer the patient to a dermatologist if there is no response to initial treatment. Individual Considerations A. Pregnancy: Use caution with medications prescribed. B. Pediatrics: For severe itching, consider oral antihistamine. Pityriasis Rosea Jill C. Cash and Amy C. Bruggemann Definition A. Pityriasis rosea is an acute, self-limiting, benign skin eruption characterized by a preceding “herald patch” that is followed by widespread papulosquamous lesions. Incidence A. Pityriasis rosea is relatively common, with more than 75% of cases in individuals from 10 to 35 years of age. 202 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Incidence is slightly higher in women than in men. C. Incidence is higher during the spring and autumn. Pathogenesis A. Disease is idiopathic; some evidence exists to support a viral origin or autoimmune disorder. Predisposing Factor A. Recent acute infection Common Complaints A. Rash: Salmon, pink, or tawny-colored lesions generally are concentrated in the trunk, but may develop on arms, legs, and rarely on the face. B. Mild pruritus Other Signs and Symptoms A. Earliest lesions may be papular but may progress to 1-to 2-cm oval plaques. B. Long axes of oval lesions run parallel to each other, hence the term “Christmas tree distribution. ” C. Preceding herald patch (2-10 cm with central clearing) closely resembles ringworm; usually appears abruptly a few days to several weeks before the generalized eruptive phase. Subjective Data A. Elicit information about occurrence of initial, single, 2-to 10-cm round to oval lesion. B. Question the patient as to known contact with similar symptoms. Small epidemics have been identified in fraternity houses and military bases. Physical Examination A. Check temperature to rule out any infection. B. Inspect 1. Examine all body surfaces with patient unclothed. 2. Look for characteristic lesions and distribution. 3. Check the mucous surfaces, palms, and soles, which are usually spared 203 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
by pityriasis rosea. Diagnostic Tests A. Generally none required; however, potassium hydroxide (KOH) wet preparation may be useful to distinguish a herald patch from tinea corporis. B. Serology to rule out syphilis, if applicable. C. If unable to identify herald patch, a serologic test for syphilis should be ordered because syphilis may be clinically indistinguishable from pityriasis rosea. D. White blood count (WBC) normal; no specific laboratory markers for pityriasis rosea. Differential Diagnoses A. Pityriasis rosea B. Nummular eczema C. Tinea corporis D. Tinea versicolor E. Viral exanthems F. Drug eruptions 1. Captopril 2. Bismuth 3. Barbiturates 4. Clonidine 5. Metronidazole G. Secondary syphilis H. Lichen planus Plan A. General interventions 1. Direct sunlight to the point of minimal erythema hastens the disappearance of lesions and decreases itching. Ultraviolet B (UVB) light in five consecutive daily exposures can decrease pruritus and shorten rash, particularly if administered within the first week of eruption. 2. Not proven to be contagious and relatively harmless, so isolation is not required. B. Patient teaching 204 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. See Section III: Patient Teaching Guide for this chapter, “Pityriasis Rosea. ” 2. Advise patients that the disease is self-limiting and clears spontaneously in 1 to 3 months. C. Pharmaceutical therapy 1. Generally none is required, but for itching the following recommendations exist: Group V topical steroids and oral antihistamines as per usual dosing. 2. Prednisone 20 mg twice daily for 1 to 2 weeks in rare cases of intense itching. Follow-Up A. None is required unless secondary infection (impetigo) develops. Disease may recur in approximately 2% of patients. Consultation/Referral A. Consult or refer the patient to a physician when disease persists beyond 3 months. Individual Considerations A. Pregnancy: Disease has not been shown to affect fetus. B. Pediatrics: Rash more frequently affects face and distal extremities. Impetigo may result from scratching or poor hygiene. C. Geriatrics: Disease is rarely seen in geriatric patients. Strongly consider other differential diagnoses, particularly drug reactions. Precancerous or Cancerous Skin Lesions Jill C. Cash and Amy C. Bruggemann Definition A. Potentially malignant or malignant cutaneous cells form precancerous or cancerous skin lesions, respectively. Incidence 205 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. There are approximately 700,000 new cases of basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) reported each year in the United States. Approximately 32,000 of these cases per year are found to be malignant melanoma. 1. SCC accounts for 20% of all skin cancers, and it occurs mostly in the middle-aged and elderly populations. 2. BCC is the most common form of skin cancer, with approximately 400,000 new cases per year in the United States. It is often seen in the sixth or seventh decade of life. 3. Malignant melanoma accounts for less than 5% of all skin cancers and is responsible for more than 60% of deaths because of skin cancer. Melanoma is frequently seen in younger people, with the median age being in the low 40s. Pathogenesis A. SCC: Abnormal cells of the epidermis penetrate the basement membrane of the epidermis and move into the dermis, producing SCC. This often begins as actinic keratosis that undergoes malignant change. B. BCC: Abnormal cells of the basal layer of the epidermis expand. The surrounding stroma supports the basal cell growth. Ultraviolet rays (sunlight) are the major contributor to BCC. BCC is a slow-growing tumor that rarely metastasizes. C. Malignant melanoma: Abnormal cells proliferate from the melanocyte system. Initially, the cells grow superficially and laterally into the epidermis and papillary dermis. After a period, the cells begin growing up into the reticular dermis and subcutaneous fat. Malignant tumors occur because of the inability of the damaged cells to protect themselves from the long-term exposure of the ultraviolet rays. D. Keratoacanthoma: Sun-exposed-area lesion that at first appears as a smooth, skin-colored, or reddish dome-shaped papule that may then grow to 1 to 2 cm in a few weeks, with crusted interior. Predisposing Factors A. Advanced age (older than age 50 years) B. Median age of 40 years for malignant melanoma C. Exposure to ultraviolet light (sun exposure) 206 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Fair complexion E. Smokers (damaged lips) F. Skin damaged by burns and/or chronic inflammation G. History of blistering sunburns before 18 years of age increases risk Common Complaints A. New lesions found on the skin B. Ulcer that does not heal Other Signs and Symptoms A. SCC: Skin lesions seen in sun-exposed areas or skin damaged by burns or chronic inflammation; lower lip lesions common; firm, irregular papules with scaly, bleeding, friable surface like sandpaper; grows rapidly B. BCC: Tumor seen on face and neck; nodules greater than 1 cm that appear shiny, pearly color with telangiectasia; center caves in C. Malignant melanoma: Asymmetrical tumor of skin with irregular border, variation in color, and greater than 6 mm in diameter; can metastasize to any organ D. Bowen's disease (SCC in situ): Chronic, nonhealing erythemic patch with sharp, irregular borders; occurs on skin and/or the mucocutaneous tissue; resembles eczema but does not respond to steroids Subjective Data A. Have the patient identify when lesion was first noted. B. Ask the patient to describe any changes in size, color, or shape of the lesion. C. Determine whether the patient has noted any new lesions. D. Ascertain any family history of malignant melanoma. E. Determine the patient's history of skin exposure to the sun or any other ultraviolet rays. F. Ask the patient about smoking history. If the patient smokes, ask how many packs per day. G. Ask if patient is up to date on routine cancer screenings. Physical Examination A. Inspect 207 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Perform full body exam of the skin for lesions 2. Note surface, size, shape, border, color, and diameter of lesion. Diagnostic Test A. Biopsy suspicious lesions. Differential Diagnoses A. SCC B. BCC C. Malignant melanoma D. Actinic keratosis E. Solar lentigo F. Seborrheic keratosis G. Common nevus H. Leukoplakia Plan A. General interventions 1. Monitor progress/change of lesions detected. 2. Biopsy any suspicious lesions. Excise lesion with narrow margins, making sure to include all margins. If biopsy results of specimen are inadequate for accurate histologic diagnosis or staging, repeat biopsy. Include all clinical history information on the pathology report with the specimen when sending to pathology. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Skin Care Assessment. ” 2. Educate patients regarding importance of early identification of lesions and monthly assessment of skin. C. Pharmaceutical therapy: None indicated. Follow-Up A. If diagnosis is made, follow up with examination every month for 3 months, twice a year for 5 years, then yearly. Consultation/Referral 208 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Refer all patients to the dermatologist if skin cancer is suspected. Individual Considerations A. Pediatrics: Teach parents to use sun protection factor (SPF) 30 or greater on pediatric patients exposed to the sun. B. Geriatrics: The elderly are at high risk of skin lesions. Monitor them closely. Psoriasis Jill C. Cash and Amy C. Bruggemann Definition A. A common benign, chronic, inflammatory skin disorder, psoriasis is characterized by whitish scaly patches commonly seen on the scalp, knees, and elbows. Incidence A. Disease occurs in about 2% of the world population. B. Psoriasis affects 2 to 8 million people in the United States. C. It occurs at any age. 1. Peaks of onset seen in young adults aged 15 to 30 years. 2. May also be seen in adults aged 57 to 60 years. Pathogenesis A. Etiology is unknown; this is a multifactorial disease with a definite genetic component. Hyperproliferation of the epidermis and inflammation of the epidermis and dermis are seen, with epidermal transit time rapidly increased (six-to ninefold). A T-lymphocyte-mediated dermal immune response may occur because of microbial antigen or autoimmune process. Predisposing Factors A. Family history B. Drugs that exacerbate condition 1. Lithium 209 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Beta-blockers 3. Nonsteroidal anti-inflammatory drugs 4. Anti-malarial 5. Sudden withdrawal of systemic or potent topical corticosteroids C. Stress (common triggering factor) D. Local trauma or irritation E. Recent streptococcal infection F. Alcohol use G. Tobacco use H. HIV association; suspected if onset is abrupt Common Complaint A. Dry scaly rash Other Signs and Symptoms A. Pruritic and/or painful lesions B. Silvery scales on discrete erythematous plaques 1. Onset commonly occurs as a guttate form with small, scattered, teardrop-shaped papules and plaques after a streptococcal infection in a child or young adult. 2. Larger, chronic plaques occur later in life. C. Lesions commonly seen on the scalp, elbows, and knees, but may involve any area of the body. D. Glossitis or geographic tongue: Small pits or yellow-brown spots (oil spots) E. Positive Auspitz sign: Punctate bleeding points with removal of scale F. Onycholysis G. Stippled nails and pitting; approximately 50% of patients have nail involvement H. Periarticular swelling of small joints of fingers and toes. Joint pain and involvement signals psoriatic arthritis. I. Pustular variant with predominant involvement of hands and/or feet, including nails Subjective Data A. Question the patient regarding any predisposing factors listed earlier to 210 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
identify risk factors. B. Ask the patient if there have been changes in the course of symptoms. C. Ascertain whether the symptoms worsen in winter and improve in summer. D. Determine the site of the lesion and whether the onset is sudden and/or painful. E. Ask the patient to describe the skin, whether it is itchy or painful. F. Assess lesions for any associated discharge (blood or pus). G. Ask if the patient is using any new soaps, creams, or lotions. H. Rule out any exposure to industrial or domestic toxins. I. Ask the patient about any possible contact with venereal disease (sexually transmitted diseases [STDs]). J. Review whether there has been any close physical contact with others with skin disorders. K. Elicit information regarding any preceding systemic symptoms (fever, sore throat, and anorexia). Physical Examination A. Check temperature (if indicated). B. Inspect 1. Inspect skin; note type of lesion and distribution. Assess oral mucosa, nails, and nail beds. 2. Assess joints. C. Palpate joints for tenderness. Diagnostic Tests A. None is indicated unless HIV infection is suspected; if so, order HIV test. B. If joint inflammation is present, consider rheumatoid factor, erythrocyte sedimentation rate, and uric acid. C. If there is a history of streptococcal infection, order antistreptolysin O titer. Differential Diagnoses A. Psoriasis B. Scalp: Seborrheic dermatitis C. Body folds: Candidiasis 211 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Trunk: Pityriasis rosea, tinea corporis E. Hand dermatitis F. SCC G. Cutaneous lupus erythematosus Plan A. General interventions 1. This is a chronic disorder that requires long-term treatment, a high degree of patient involvement, and therapy that is simple and inexpensive. 2. Aim of treatment is control, not cure. 3. Exposure to sunlight may be beneficial. However, symptoms worsen in a small percentage of patients with exposure to sunlight. 4. Mild to moderate disease may be treated with phototherapy if allowable because of cost. 5. Sequence of agents for involvement of less than 20% body surface is as follows: a. Emollients (Eucerin cream or Aquaphor cream) b. Keratolytic agents (salicylic acid gel or ointment) c. Topical corticosteroids: Use lowest potency to control disease. d. Calcipotriene ointment: Vitamin D analogue (calcipotriene ointment 0. 005%) e. Anthralin: Use as short-contact therapy 1% to 3%. f. Coal tar (Estar, Psori Gel): Use in conjunction with topical steroids or anthralin. May apply at bedtime or in the morning for 15 minutes and then shower off. g. Medicated shampoos: Useful for scalp psoriasis, in conjunction with topical steroids and other treatments. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Psoriasis. ” 2. Help the patient understand the chronic nature of this disease characterized by flares and remission. Teach stress monitoring and control. Assist with coping techniques. 3. A trial of a gluten-free diet may be tried to help symptoms. See Appendix B : “Gluten-Free Diet. ” 4. If phototherapy is not effective, systemic agents are recommended. C. Pharmaceutical therapy: If the disease is not controlled with the first 212 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
agent, then an alternative agent may be tried. 1. Mild to moderate disease: Topical steroids as first-line therapy. 2. Emollients to start treatment (e. g., Eucerin Plus lotion or cream, Lubriderm Moisture Plus, Moisturel) 3. Scalp: Use coal tar shampoo (Zetar, T/Gel, Pentrax) in place of regular shampoo two times per week. a. Apply lather to scalp, allow to soak for 5 minutes, and then rinse. b. If plaques are very thick, use P and S Liquid (over the counter [OTC]). Massage in at night and wash out in the morning. 4. For additional treatment as needed, apply triamcinolone acetonide 0. 1% (Kenalog 0. 1%) lotion or equivalent to scaly, stubborn areas once or twice daily until controlled. Avoid face. 5. Dovonex scalp solution: Apply on dry scalp as directed. 6. Face and skin folds: Hydrocortisone cream 1%, apply sparingly up to 4 weeks, preferably no more than 2 weeks. If lesions are unresponsive, consider increasing to 2. 5% and taper quickly with improvement. 7. Body, arms, and legs: Use triamcinolone acetonide 0. 025% (Aristocort A) cream twice daily up to 2 weeks. Avoid normal skin. 8. For thick plaques, try Keralyt gel (6% salicylic acid), then corticosteroids. 9. Use coal tar (Estar gel) once or twice daily in combination with corticosteroids. 10. Anthralin (Dritho-Creme) is beneficial as an alternate to steroid lotion for scalp psoriasis. Avoid sunlight. 11. Vitamin D3 analogue: (Calcipotriol), twice daily up to 8 weeks, is comparable to midpotency corticosteroids. Avoid face and skin folds. 12. Systemic agents for moderate to severe psoriasis may be used if other measures fail. Systemic agents should be prescribed by a dermatology specialist; these medications include retinoids, methotrexate, cyclosporine, and apremilast. These medications should be monitored closely for liver/kidney function changes. Follow-Up A. See patients in 2 to 3 weeks to evaluate treatment. B. Follow up in 2 months to monitor side effects. 213 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Follow-up must be individualized for each patient. Consultation/Referral A. Medical management: For involvement greater than 20% of body, refer the patient to a dermatologist for the following: 1. Light therapy with ultraviolet A (UVA) or UVB. UVB light therapy is often used in conjunction with keratolytic agents. 2. Synthetic retinoids: Etretinate or acitretin are options. 3. Low-dose cyclosporine or Azulfidine can be effective. B. Refer patients with extensive disease, psoriatic arthritis, or inflammatory disease to a rheumatologist. New medications, called biologics, are used to suppress the immune system's response, which include adalimumab (Humira), alefacept (Amevive), etanercept (Enbrel), infliximab (Remicade), and ustekinuman (Stelara). C. Cases of generalized pustular psoriasis of exfoliative erythroderma should be referred immediately to a dermatologist. D. All systemic therapies should be given under supervision of a dermatologist or rheumatologist. Individual Considerations A. Adults 1. Patients with moderate to severe disease that is not well controlled should be referred to a dermatology specialist for systemic treatment. Scabies Jill C. Cash and Amy C. Bruggemann Definition A. Scabies is a contagious skin infestation by the mite Sarcoptes scabiei. Incidence A. Scabies occurs mainly in individuals in close contact with many other individuals such as schoolchildren or nursing-home residents. It is rare among African Americans. 214 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Pathogenesis A. Scabies is transmitted through close contact with an individual who is infested with the mite S. scabiei. Transmission may occur through sexual contact or contact with mite-infested clothing or sheets. The fertilized female mite burrows into the stratum corneum of a host and deposits eggs and fecal pellets. Larvae hatch, mature, and repeat the cycle. B. A hypersensitivity reaction is responsible for the intense pruritus. Predisposing Factors A. Close contact with large numbers of individuals B. Institutionalized C. Poverty D. Sexual promiscuity Common Complaints A. Intense itching, worse at night B. Skin excoriation C. Generalized pruritus D. Rash Other Signs and Symptoms A. Mites burrow in finger webs, at wrists, in the sides of hands and feet, at the axilla buttocks, and in the penis and scrotum in males. B. Discrete vesicles and papules, distributed in linear fashion. C. Erythema is a symptom. D. Secondary infections caused by scratching or infection (pustules and pinpoint erosions). E. Nodules in covered areas (buttocks, groin, scrotum, penis, and axilla), which may have slightly eroded surfaces that persist for months after mites have been eradicated F. Diffuse eruption that spare the face. Subjective Data A. Elicit information regarding housing conditions, close contact, or sexual contact with potentially infected individuals. 215 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Question the patient regarding onset, duration, and location of itching. Physical Examination A. Check temperature. B. Inspect 1. Examine all body surfaces with patient unclothed. 2. Use a magnifying lens to identify characteristic burrows in finger webs, wrists, and penis. 3. Inspect adult pubic area for lesions. Diagnostic Tests A. Three findings are diagnostic of scabies: 1. Microscopic identification of S. scabiei mites 2. Eggs 3. Fecal pellets (scybala) B. Burrow identification: Ink the suspected area with a blue or black felt-tipped pen, then wipe with an alcohol swab. The burrow absorbs the ink, while the surface ink is wiped clean. C. A tiny black dot may be seen at the end of a burrow, which represents the mite, ova, or feces, and can be transferred by means of a 25-gauge hypodermic needle to immersion oil on a slide for microscopic identification. D. Place a drop of mineral oil on a suspected lesion, scrape the lesion with a #15 blade, and transfer the shaved material to a microscope slide for direct examination of the mite under low power. Differential Diagnoses A. Scabies B. Atopic dermatitis C. Insect bites D. Pityriasis rosea E. Eczema F. Seborrheic dermatitis G. Syphilis H. Pediculosis I. Allergic or irritant contact dermatitis 216 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Plan A. General interventions 1. Implement comfort measures to reduce pruritus. 2. Treat secondary infection(s) with antibiotics. 3. Household members should be treated simultaneously as a prophylactic measure and to reduce the chance of reinfection. 4. The patient should be advised that pruritus may continue for up to a week even with a successful treatment because of local irritation. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Scabies. ” C. Pharmaceutical therapy 1. First line of therapy, because of its low toxicity, is 5% permethrin (Elimite cream) applied to all body areas from the neck down and washed off in 8 to 14 hours. One application is highly effective, but some dermatologists recommend retreatment in 1 week. 2. Alternative therapy is lindane (Kwell) cream, applied to all skin surfaces from the neck down and washed off in 8 to 12 hours. Some dermatologists retreat in 1 week. 3. A single oral dose of the anthelmintic agent ivermectin (200 mcg/kg) has been shown to be effective and to rapidly control pruritus in healthy patients and HIV patients. 4. Diphenhydramine (Benadryl) 25 to 50 mg may be given by mouth every 4 to 6 hours if indicated for pruritus. Other nonsedating antihistamines may be used. Toxicity is usually a result of patient overtreatment (failure to follow prescribed regimen). Advise the patient of this danger. Follow-Up A. Follow up in 2 weeks to assess treatment response. Consultation/Referral A. Consult or refer the patient to the physician if, at 2-week follow-up, pharmaceutical therapy has been ineffective. Individual Considerations 217 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Pregnancy 1. Permethrin is preferred to lindane in pregnant and/or lactating women because of decreased toxicity. 2. Patient should be warned of its potential to cause neurotoxicity and convulsions with overuse (more than two treatments). B. Pediatrics 1. Infants and toddlers often have more widespread involvement that can include the face and scalp. 2. Vesicular lesions on palms and soles are more commonly seen. 3. Drug of choice is permethrin 5% cream; apply over the head, neck, and body, avoiding the eyes. The cream should be removed by bathing within 8 to 14 hours. 4. Lindane should not be used in infants and toddlers. 5. Infants and children with underlying cutaneous disease, malnutrition, prematurity, or a history of seizure disorders should be treated with special caution because of their increased risk of toxicity. C. Partners: All intimate contacts within the past month and close household and family members should be treated. D. Geriatrics 1. The elderly tend to have more severe pruritus despite fewer lesions. 2. They are at risk of extensive infections because of age-related decline in immunity. 3. The excoriations may become severe and may be complicated by cellulitis. Seborrheic Dermatitis Jill C. Cash and Amy C. Bruggemann Definition A. A common chronic, erythematous, scaling dermatosis, seborrheic dermatitis occurs in areas of the most active sebaceous glands such as the face and scalp, body folds, and presternal region. Incidence 218 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Seborrheic dermatitis is very common. B. Incidence is higher in HIV-infected individuals. Pathogenesis A. Etiology is unknown. There is a possibility that it is hormonally dependent, has a fungal (Pityrosporum ovale or Candida albicans) component, is neurogenic, or may reflect a nutritional deficiency. B. Currently, it is identified as an inflammatory disorder that most probably results from a dysfunction of sebaceous glands. Predisposing Factors A. Possible link between infantile and adult forms B. Possible familial trend C. High association with HIV-infected individuals Common Complaints A. Infants: “Cradle cap” B. Adults: “Dandruff,” dry flaky scalp C. Rash with “sticky flakes” Often no presenting complaints are found on a routine physical examination. Other Signs and Symptoms A. Variable pruritus, often increasing with perspiration and in winter B. Oily, flaking skin on erythemic base around ears, nose, eyebrows, and eyelids C. Red, cracking skin in body folds; axilla; groin; or anogenital, submammary, or umbilical areas D. Primary lesions: Plaques E. Secondary lesions: Erythema, scales, fissures, exudate, and symmetric eyelid involvement F. Lesions with drainage or crusting may indicate secondary bacterial infection 219 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Distribution pattern in infants: Scalp and diaper area H. Distribution area in adults: Scalp, eyebrows, paranasal area, nasolabial fold, chin, behind ears, chest, and groin I. Secondary impetigo in children Subjective Data A. Identify location, onset, and progression of symptoms. B. Ask the patient to describe symptoms. Ask if the skin is itchy or painful. C. Assess lesions for any associated discharge (blood or pus). D. Elicit information regarding use of topical medications, soaps, creams, or lotions. Quiz the patient regarding any oral medications being taken. E. Determine whether there were any preceding systemic symptoms (fever, sore throat, anorexia, or vaginal discharge). F. Rule out any possible exposure to industrial or domestic toxins. G. Ask the patient to identify what improves or worsens this condition. Physical Examination A. Inspect 1. Inspect skin; note areas of lesions and distribution. 2. Assess eyes for blepharitis. 3. Inspect ears and nose. B. Palpate skin, noting texture and moisture. Diagnostic Tests A. None required. B. Consider fungal culture in children and adolescents to rule out a fungal infection. C. Consider possible skin biopsy to rule out other conditions. Differential Diagnoses A. Seborrheic dermatitis B. Atopic dermatitis C. Candidiasis D. Dermatophytosis E. Histiocytosis X F. Psoriasis vulgaris 220 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Rosacea H. Systemic lupus erythematosus I. Tinea capitis J. Tinea versicolor K. Vitamin deficiency L. Impetigo M. Eczema Plan A. General interventions 1. Shampooing is the foundation of treatment. a. Infants: Rub petroleum jelly into scalp to soften crusts 20 to 30 minutes before shampooing. b. Shampoo daily with baby shampoo using a soft brush. c. Toddlers or adolescents: Shampoo every other day with antiseborrheic shampoo (Selsun Blue, Exsel, or Nizoral). 2. If skin does not clear after 1 to 2 weeks of treatment, it is appropriate to use ketoconazole 2% cream. 3. Seborrheic blepharitis a. Hot compresses plus gentle debridement with cotton-tipped applicator and baby shampoo twice a day b. For secondary bacterial infection, sulfacetamide sodium 10% (ophthalmic Sodium Sulamyd) 4. Continue treatment for several days after lesions disappear. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Seborrheic Dermatitis. ” C. Pharmaceutical therapy 1. Most shampoos should be used two times per week. Those with coal tar can be used three times per week. 2. Medicated shampoos a. Coal tar (Denorex, T/Gel, Pentrax, Tegrin) shampoo, apply as directed. b. Salicylic acid (Ionil Plus, P and S) shampoo, apply as directed. c. Selenium sulfide (Exsel, Selsun Blue) shampoo, use daily. d. Ketoconazole 2% (Nizoral) cream, apply to affected area twice daily for 4 to 6 weeks. 221 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
e. Combination shampoos: Coal tar and salicylic acid (T/Sal); salicylic acid and sulfur (Sebulex). These shampoos may be used one to two times a week, alternating with other shampoos during the week. Always apply corticosteroids in a thin layer only; avoid the eyes. 3. Topical corticosteroid lotions or solutions: Use in combination with medicated shampoo if 2 to 3 weeks of treatment with shampoo alone fails. 4. Adults: Scalp a. Start with medium potency, for example, betamethasone valerate 0. 1% lotion twice daily. b. If treatment is not effective in 2 weeks, increase potency, for example, fluocinonide 0. 05% solution twice daily, or fluocinolone acetonide 0. 01% oil 120 m L nightly with shower cap. c. As dermatitis is controlled, decrease to mild potency, for example, hydrocortisone 1% to 2. 5% lotion once or twice daily. 5. Adults: Face or groin a. Low-potency agents, for example, hydrocortisone 1% cream or desonide 0. 05% cream once or twice daily b. Consider lotion for eyebrows for easier application. c. Metronidazole 1% gel on face once or twice daily 6. Recalcitrant disease a. Add ketoconazole 2% cream (15, 30, or 60 g) every day. b. Use sulfacetamide sodium 10%, with sulfur 5%, lotion 25 g once or twice daily. Follow-Up A. Tell the patient to call the office in 5 to 6 days to report progress. B. Have the patient return to the office if no improvement is seen. Consultation/Referral A. Refer the patient to a dermatologist if the condition does not clear in 10 to 14 days. Individual Considerations A. Pregnancy: Ketoconazole is not recommended. B. Pediatrics 1. Avoid using tar preparations on infants. 222 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Use baby shampoo only. 3. If lesions are inflammatory, use topical steroids no stronger than hydrocortisone 0. 5% to 1. 0% twice daily. 4. Betamethasone valerate (Valisone) lotion may be used daily for scalp only if other treatments fail. 5. Be aware of potential for emotional distress in adolescents. 6. Treat with antiseborrheic shampoo every other day for adolescents. Tinea Corporis (Ringworm) Jill C. Cash and Amy C. Bruggemann Definition A. Tinea corporis (ringworm) is a fungal infection of the skin tissue (keratin) commonly seen on the face, trunk, and extremities. Incidence A. Ringworm is a fairly common fungal infection seen in adults and children. Pathogenesis A. The causative fungal species varies, depending on the location of the infection. Three common organisms are Epidermophyton, Microsporum, and Trichophyton. B. The infection can be obtained from other people, animals (puppies, kittens), and the soil. Predisposing Factors A. Exposure to person or facilities (e. g., locker rooms) infected with the fungus B. Poor nutrition C. Poor health D. Poor hygiene E. Warm climates F. Immunosuppression 223 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Common Complaint A. Scaly, itchy patch of skin, often circular in shape Other Signs and Symptoms A. Tinea capitis: Erythema, scaling of scalp, with hair loss at site asymptomatic B. Tinea corporis: Circular, erythematous, well-demarcated lesion on the skin with hypopigmentation in center of lesion; usually pruritic C. Tinea cruris: Well-demarcated scaling lesions on groin (not scrotum) or thigh; usually pruritic D. Tinea pedis: Scaly, erythemic vesicles on feet, between toes, and in arch, with extreme pruritus E. Tinea unguium (onychomycosis): Thickening and yellowing of toenail or fingernail, often with other fungal infection or alone Subjective Data A. Ask the patient about onset, duration, and progression of the patch or rash on the skin. B. Assess the patient about other areas of skin involvement. C. Ask if the lesion is pruritic. D. Inquire as to the patient's exposure to anyone with similar symptoms. E. Determine whether the patient has a history of similar lesions. F. Query the patient regarding predisposing factors. G. Review with the patient what remedies were used and with what results. Physical Examination A. Check temperature (if indicated). B. Inspect 1. Examine all areas of skin. 2. Note type of lesions present. Diagnostic Tests A. Obtain scrapings of the border of the lesion for evaluation. 1. Potassium hydroxide (KOH) 2. Wet prep 224 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Fungal cultures Differential Diagnoses A. Tinea corporis B. Dermatitis C. Alopecia areata D. Psoriasis E. Contact dermatitis F. Atopic eczema Plan A. General interventions 1. Identify type of lesion. 2. Identify other infected family members or sexual partners for treatment. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Ringworm Tinea. ” 2. Reinforce medication regimen for 4-to 8-week period for resolution. C. Pharmaceutical therapy 1. Tinea capitis a. Adults: Griseofulvin 500 mg by mouth per day for 4 to 8 weeks b. Children: Griseofulvin 10 to 20 mg/kg/d for 4 to 8 weeks. Griseofulvin is best absorbed with high-fat foods. c. Ketoconazole (Nizoral) may also be used. 2. Tinea corporis, pedis, and cruris: Use wet dressings with Burow's solution along with one of the following: a. Clotrimazole 1% (Lotrimin) cream, or econazole nitrate 1% cream, twice daily for 14 to 28 days b. Terbinafine 1% cream (Lamisil), topical, apply once or twice daily for 1 to 4 weeks. Not recommended for children. 3. Onychomycosis: Successful treatment is difficult. a. Itraconazole (Sporanox) 100 mg, two tablets by mouth twice daily for 7 days. Repeat in 1 month, then repeat again in 1 more month. 225 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Monitor liver function tests (LFTs) at 6 weeks after starting medication. b. Terbinafine 1% cream (Lamisil) i. Fingernail:250 mg once daily for 6 weeks ii. Toenail:250 mg daily for 12 weeks c. Home cure: Apply Vicks Vapo Rub on toenail bed every night at bedtime for approximately 4 to 6 months or until resolved. This treatment offers a safe, cost-effective alternative to oral medications. Follow-Up A. A 2-to 4-week follow-up is recommended to evaluate progress. B. Monitor LFT at 6 weeks and if itraconazole (Sporanox) is continued longer. Consultation/Referral A. Consult a physician if the infection has not improved. Individual Considerations A. Pregnancy: Oral antifungal medications are not recommended during pregnancy. B. Pediatrics 1. Tinea capitis is common in children 2 to 10 years old. When hair has been lost, regrowth takes time. 2. Tinea pedis is common in adolescents. 3. Tinea unguium is common in adolescents, but rare in children. C. Adults 1. Tinea capitis is rare in adults. 2. Tinea cruris is more common in obese males, but rare in females. 3. Tinea pedis is common in adults. 4. Tinea unguium is seen in adults. Tinea Versicolor Jill C. Cash and Amy C. Bruggemann 226 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Definition A. Tinea versicolor is a fungal infection of the skin, which may be chronic in nature. It is most commonly seen on the upper trunk; however, it may spread to extremities. Incidence A. Tinea versicolor is seen most frequently in adolescents and young adults. Pathogenesis A. Tinea versicolor is a fungal infection of the skin caused by an overgrowth of Pityrosporum orbiculare, part of the normal skin flora. B. Discoloration of the skin is seen, forming round or oval maculae, which may become confluent. C. Maculae range from 1 cm to very large, greater than 30 cm. Predisposing Factors A. Immunosuppressive therapy B. Pregnancy C. Warm temperatures D. Corticosteroid therapy Common Complaint A. Scaly rash on the upper trunk with occasional mild itching Other Signs and Symptoms A. Annular maculae with mild scaling B. Asymptomatic or pruritic C. Pink-, white-, or brown-colored rash Subjective Data A. Ascertain when and where the rash began. B. Have the patient describe how the rash has changed. C. Assess the patient for any associated symptoms with the rash such as itching and burning. D. Identify what products the patient has used on the skin to treat rash and 227 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
with what results. E. Elicit information regarding a history of similar rashes. F. Query the patient regarding current medications. G. Review any medical history for comorbid conditions. Physical Examination A. Inspect 1. Inspect skin and note type of lesion. 2. Examine other areas of skin for similar lesions. Diagnostic Tests A. Wet prep/potassium hydroxide (KOH) B. Wood's lamp: Wood's lamp is useful in examining skin to determine the extent of infection. Inspection of fine scales with Wood's lamp reveals scales with a pale yellow-green fluorescence that contains the fungus. C. Culture lesion: When obtaining a sample scraping, obtain the sample from the edge of the lesion for the best sample of hyphae. (Hyphae and spores have a “spaghetti and meatball” appearance. ) Differential Diagnoses A. Tinea versicolor B. Tinea corporis C. Pityriasis alba D. Pityriasis rosea: Herald patch is clue to diagnosis E. Seborrheic dermatitis F. Vitiligo Plan A. General interventions: Apply medication as directed. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Tinea Versicolor. ” 2. These causative species are a normal inhabitant of skin flora; recurrence is possible. 3. Skin pigmentation returns after infection is cleared up. This may take several months to resolve. 228 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Pharmaceutical therapy 1. Selenium sulfide 2. 5% (Selsun Blue) a. Apply to skin at bedtime one time. Shower off in the morning. b. For 12 days, apply Selsun Blue to skin lesions, wait 30 minutes, and then shower off. c. Treatment may be needed monthly until desired results are obtained. Encourage use of Selsun Blue on entire body surface except for face and head. 2. Other medications used a. Clotrimazole 1% cream twice daily for 4 weeks b. Ketoconazole (Nizoral) cream daily for 14 days c. Ketoconazole (Nizoral) 200 mg by mouth once daily for 3 days, for adults only. When using ketoconazole (Nizoral) as treatment, caution the patient regarding liver damage with toxicity. Follow-Up A. None is required if resolution occurs. B. Monitor liver function tests (LFTs) every 6 weeks if patient is on ketoconazole. Consultation/Referral A. Consult with a physician if current treatment is unsuccessful. Individual Considerations A. Pediatrics: Commonly seen in adolescents B. Adults: Commonly seen in young adults Warts Jill C. Cash and Amy C. Bruggemann Definition A. A wart is an elevation of the epidermal layer of the skin (skin tumor). Warts are caused by the papillomavirus. Incidence 229 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Warts occur in people of all ages, more common in children and during early adulthood. B. By adulthood, 90% of all people have positive antibodies to the virus. C. Warts are seen more frequently in females than in males. Pathogenesis A. A circumscribed mass develops on the skin that is limited to the epidermal layer. The virus, papillomavirus, is located within the nucleus of the cell. B. The virus may be transmitted by touch and is commonly seen on the hands and feet. C. Most warts resolve without treatment within 12 to 24 months. Predisposing Factors A. Skin trauma B. Immunosuppression C. Exposure to public showers, pools, locker rooms, and so forth Common Complaints A. Bump on the skin or specific area of the body (hands, feet, arms, and legs) B. Usually painless unless present on the bottom of the foot Other Signs and Symptoms A. Common wart (verruca vulgaris): Flesh-colored, irregular lesion with rough surface; black dots in center of lesion occasionally seen, which is thrombosed capillaries; can occur on any body part B. Filiform wart (verruca filiformis): Thin, threadlike, projected papule on face, lips, nose, or eyelids C. Flat wart (verruca plana): Flat-topped, flesh-colored papule, 1 to 3 mm in diameter, with smooth surface; seen in clusters or in a line, on face and extremities D. Plantar wart (verruca plantaris): Firm papula, 2 to 3 cm in diameter, indented into skin with verrucous surface; painful with ambulation, when placed on ball or heel of foot E. Genital warts: See Chapter 15: Sexually Transmitted Infections 230 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Guidelines. Subjective Data A. Determine onset, location, and duration of tumor. B. Elicit information regarding a history of previous warts. C. Identify with the patient what treatment has been used in the past and what the results were. Question the patient regarding length of time over-the-counter (OTC) medications were used, and how aggressive he or she was with the treatment. Physical Examination A. Inspect 1. Assess skin for lesions, noting location, appearance, size, and surface texture of tumor. 2. Examine the entire body for other lesions. Diagnostic Test A. None indicated Differential Diagnoses A. Wart 1. Verruca vulgaris 2. Verruca filiformis 3. Verruca plana 4. Verruca plantaris B. Seborrheic keratosis C. Callus D. Molluscum contagiosum: Flesh-colored group of firm papules found on the face, trunk, and/or extremities. A white core may be expressed from the lesion. Lesion may be successfully removed by curettage or cryotherapy. Plan A. General interventions 1. Identify the type of wart. 2. Conservative treatment is recommended for children. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, 231 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
“Warts. ” C. Pharmaceutical therapy 1. Common wart: After soaking and filing wart with a nail file, apply one of these: a. Salicylic acid 17% (Compound W) gel twice daily for up to 12 weeks, if needed. Keep site covered with adhesive. b. Apply duct tape to site after treatment. Repeat this treatment every night for up to 12 weeks or until resolved. c. Cryotherapy with liquid nitrogen to site. Repeat every 3 to 4 weeks until resolved. Apply adhesive tape over site and keep covered. 2. Flat wart or filiform wart a. Retinoic acid; apply to site twice daily for 4 to 6 weeks. b. Aldara (imiquimod) 5% cream may be applied by the patient at home. Although the labeled use is for genital warts, the patient may consider off-label use at bedtime and wash off after 6 to 8 hours every other day until resolved. Precautions should be stressed regarding the caustic nature of the cream to healthy skin. 3. Plantar wart: Salicylic acid 40% (Mediplast), apply over wart. Remove in 24 to 48 hours, and remove dead skin with a pumice stone or by scraping or using a nail file. Repeat every 24 to 48 hours until wart is removed. May take up to 6 to 8 weeks. 4. Educate the patient to throw away the emory board nail file after each use. If using a nail file, after each use, cleanse with alcohol. Follow-Up A. Follow the patient every 4 to 6 weeks until resolved. Consultation/Referral A. If diagnosis is unclear, refer the patient to a dermatologist for surgical excision and biopsy. Individual Consideration A. Pediatrics: Warts are commonly seen in young school-aged children. Wound Care 232 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Lower Extremity Ulcer Amy C. Bruggemann Definition A. Vascular ulcer 1. Arterial/ischemic ulcer a. Skin ulcers usually found on the medial or lateral foot or ankle; ulcers are nonhealing because of inadequate arterial flow. 2. Venous ulcer a. Chronic skin and subcutaneous lesions are usually found on the lower extremity between the ankle and knee, thought to occur from intracellular edema or inflammatory processes. B. Diabetic foot ulcer 1. Skin ulcers are usually found on the plantar surface of the foot, most commonly occurring from trauma or plantar pressure. Incidence A. Diabetic foot ulcers precede more than 80% of lower extremity amputations in the United States. B. The financial burden of venous ulcers is estimated to be $2 billion per year in the United States. C. Up to 20% of lower extremity ulcers have been shown to have mixed etiology disease. Pathogenesis A. An ulcer that is found between the knees and toes constitutes a lower extremity ulcer, and guidelines are based according to the etiology. The thing to remember with lower extremity ulcers is that they may have more than one cause. The most common etiologies are venous insufficiency, arterial insufficiency, diabetic foot ulcer, and/or pressure of time. Predisposing Factors A. Arterial insufficiency B. Congestive heart failure 233 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Coronary artery disease D. Diabetes E. Edema F. Hyperlipidemia G. Obesity H. Age: Older than 65 years I. Venous insufficiency J. Peripheral neuropathy Common Complaints A. Lower extremity or foot pain B. Bleeding C. Drainage D. Hyperglycemia Subjective Data A. Ask the patient to describe the location and onset. What does he or she think may have been the cause? Was the onset sudden or gradual? How have the symptoms continued to develop? B. Assess if the area is itchy or painful. Does the patient feel the area? C. Assess for any associated drainage. Ask about the color and if any odor is noted. D. Complete a drug history. Ask the patient if he or she is taking any steroids or anticoagulants. E. Has the patient been treated in this location location before? If so, describe. F. Determine whether the patient has attempted to treat this at home. If yes, with what? G. Does the patient have any numbness or tingling in the lower extremities? Does the patient wake up at night with pain? Does he or she have any pain with ambulation? Does he or she have sensation in the feet? H. Rule out any possible exposure to industrial or domestic toxins, or insect bites. I. Assess for iodine and sulfa allergies before starting treatment. Physical Examination 234 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Check temperature, pulse, respiration, and blood pressure. B. Inspect 1. Assess the lower extremities, feet, and toes. a. Color of the skin: i. Assess skin; begin at the top of the legs, move down the legs to the toes looking for changes in color that may exhibit signs of ischemia. ii. Hemosiderin staining may exhibit venous insufficiency. 2. Inspect the ulcer. a. Measure length × width × depth: i. Undermining: Measure and note location, using the face of a clock to document the site of undermining:12 o'clock, 3 o'clock, 6 o'clock, or 9 o'clock. ii. Tunneling: Measure and note the location, using the face of a clock to document the site of tunneling:12 o'clock, 3 o'clock, 6 o'clock, or 9 o'clock. b. Describe the wound bed. i. Tissue in the wound bed 1)Necrotic tissue, granulation tissue, or epithelial tissue ii. Color of the tissue (percentage to equal 100%, i. e., 80% pink, 20% yellow) 1)Red, pink, yellow, brown, tan, or black iii. Drainage 1)Amount a)None, scant, moderate, or copious 2)Color a)Serous, sanguineous, purulent, yellow, serosanguineous, or green iv. Odor v. Periwound 1)Intact 2)Not intact a)Describe periwound: Note erythema, fever, induration, maceration, excoriation, calloused, or epiboly C. Palpate 1. Note temperature of the skin. 235 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Assess sensation of the skin. 3. Check capillary refill. 4. Assess pulses in bilateral extremities. Diagnostic Tests A. Ankle brachial index (ABI) B. Arterial Doppler C. Bone scan D. CBC E. Hemoglobin A1c (Hgb A1c) F. MRI G. Wound culture H. Wound biopsy I. Venous Doppler J. X-ray Differential Diagnoses A. Vascular ulcer 1. Arterial/ischemic ulcer 2. Venous ulcer B. Diabetic foot ulcer C. Abscess D. Atypical ulcers E. Dermatological disorder F. Necrotizing fasciitis G. Skin cancers H. Pressure ulcer I. Trauma J. Pyoderma gangrenosum Plan General Interventions A. Vascular ulcers 1. Arterial ulcer a. Refer to vascular surgery for assessment to improve arterial flow. 236 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b. Refer to wound care specialist. 2. Venous ulcer a. Establish arterial flow. i. Refer to vascular surgeon if deficiency found. b. For signs and symptoms of infection, treat the infection first with tissue culture and sensitivity. Treat per pharmaceutical recommendations. Treat with silver alginate to the site for moderate drainage and silver gel to the site for scant drainage. c. Once arterial flow has been established as sufficient and infection has been ruled out, compression therapy is the mainstay of treatment for venous ulcers. Compression therapy recommendations: i. ABI:0. 8 to 1. 0 full compression 1)Pro-fore a)Change in 3 days; if tolerating, then change weekly. ii. ABI:0. 6 to 0. 8 Light compression 1)Pro-fore lite 2)Apply calcium alginate to ulcer, then wrap with a Unna Boot, and then cover with a coban wrap. a)Change in 3 days; if tolerating well, then change weekly. B. Diabetic foot ulcer 1. Establish arterial flow. a. Refer to a vascular surgeon if deficiency found. 2. For signs and symptoms of infection, use a sterile culturette to obtain a tissue culture and sensitivity first to assess what organism is present and to determine sensitivities. Treat per pharmaceutical recommendations. Treat with silver alginate to the site for moderate drainage, and silver gel to the site for scant drainage. 3. Initiate offloading to site. a. Refer to an orthotist for assessment if devices are required. 4. Treatment options a. To debride: Cleanse with normal saline (NS), apply Santyl, and change dressing daily and as needed. b. To granulate an ulcer with scant drainage: Cleanse with NS, apply hydrogel, and change dressing daily and as needed. c. To granulate an ulcer with moderate drainage: Cleanse with NS, 237 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
apply calcium alginate, and change dressing daily as needed. C. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Wound Care: Lower Extremity Ulcers. ” D. Pharmaceutical therapy 1. If culture and sensitivity are performed, antibiotics may be used as recommended per sensitivity. Follow-Up A. Follow up in 1 to 2 weeks to evaluate therapy. B. See patients every 1 to 2 weeks until healing well; then patient may reduce to 2-to 4-week evaluation until complete closure. Consultation/Referral A. Consult or refer the patient to a wound care specialist when the patient has: 1. Extensive ulcer that you are not comfortable with a. Visible bone, muscle, or tendon 2. Multiple medical comorbidities (especially diabetes) 3. Not responded to treatment of 2 to 4 weeks 4. Ulcer showing decline on follow-up visit 5. Infection present Individual Considerations A. Adults 1. Ischemic ulcers warrant immediate referral 2. Complaints of severe pain, lack of pulse, cool digit, or new onset of purplish/bluish discolorations to the feet require immediate workup for arterial clot to lower extremity. Pressure Ulcers Amy C. Bruggemann Definition A. “A pressure ulcer is localized damage to the skin and/or underlying soft 238 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
tissue, usually over a bony prominence, or related to a medical or other device. The injury can present as intact skin or related to a medical or other device. The injury occurs as a result of intense pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue” (Diagnosis; used with permission from the National Pressure Ulcer Advisory Panel [NPUAP], 2016). Incidence A. Acute care: 0. 4% to 38% B. Long-term care: 2. 2% to 23. 9% C. Home care: 0% to 17% Pathogenesis A. Pressure ulcers occur when an area of tissue remains in surface contact for a period of time. This contact causes occlusion of microvascular vessels, which leads to tissue hypoxia and eventually may cause ischemia. Over time, a pressure ulcer develops. The amount of time this takes is patient dependent and can be altered by physical and/or environmental factors of time. Predisposing Factors A. Acute illness B. Fecal/urinary incontinence C. Malnutrition D. Weight loss E. Failure or inability to offload 1. For example, fracture, elevation of head of bed (HOB), lack of education, or noncompliance Common Complaints A. Pain B. Bleeding Subjective Data A. Ask the patient to describe the location and onset. What did he or she think may have been the cause? Was the onset sudden or gradual? How have 239 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the symptoms continued to develop? B. Assess if the area is itchy or painful. C. Assess for any associated drainage. Ask about the color and if any odor is noted. D. Complete a drug history. Ask the patient if he or she is taking any steroids or anticoagulants. E. Has the patient been treated in this location before? If so, describe. F. Determine whether the patient has attempted to treat this problem at home. If yes, ask with what. G. Rule out any possible exposure to industrial or domestic toxins, or insect bites. H. Assess for iodine and sulfa allergies before starting treatment. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect the pressure ulcer. 1. Measure length × width × depth. a. Undermining: Measure and note location, using the face of a clock to document the site of undermining:12 o'clock, 3 o'clock, 6 o'clock, or 9 o'clock. Undermining is documented as from one time to another. b. Tunneling: Measure and note location, using the face of a clock to document the site of tunneling. Tunneling is documented at one point of time per the clock face 2. Describe the wound bed: a. Tissue in the wound bed i. Necrotic tissue, slough tissue, granulation tissue, or epithelial tissue b. Color of the tissue (percentage to equal 100%, i. e., 80% pink, 20% yellow): i. Red, pink, yellow, brown, tan, or black c. Drainage i. Amount 1)None, scant, moderate, or copious ii. Color 1)Serous, sanguineous, purulent, yellow, serosanguineous, or green 240 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
d. Odor e. Periwound i. Intact ii. Not intact 1)Erythema, fever, induration, maceration, excoriation, calloused, or epiboly Diagnostic Tests A. CBC B. Wound culture C. Wound biopsy D. X-ray E. MRI F. Bone scan Diagnosis A. Stage 1: Pressure injury—Nonblanchable erythema of intact skin 1. Definition: Intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue injury. B. Stage 2: Pressure injury—Partial-thickness skin with exposed dermis 1. Definition: Partial-thickness loss of skin with exposed dermis. The wound bed is visible, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). C. Stage 3: Pressure injury—Full-thickness skin loss 1. Definition: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are 241 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. D. Stage 4: Pressure injury—Full-thickness skin and tissue loss 1. Definition: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. E. Unstageable pressure injury: Obscured full-thickness skin and tissue loss 1. Definition: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i. e., dry, adherent, intact without erythema, or fluctuance) on an ischemic limb or the heel(s) should not be removed. F. Deep tissue pressure injury (DTPI): Persistent non-blanchable deep-red, maroon, or purple discoloration 1. Definition: Intact or nonintact skin with localized area of persistent nonblanchable deep-red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change of skin precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, Stage 3, or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. H. Additional pressure injury definitions: This describes an etiology. Use the staging system to stage: 242 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Medical device-related pressure injury: This describes the etiology of the injury. Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. 2. Mucosal membrane pressure injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged. Differential Diagnoses A. Abscess B. Trauma C. Skin cancer D. Vascular ulcer E. Diabetic foot ulcers F. Dermatological disorder G. Venous ulcer Plan A. General interventions 1. Identify the cause of pressure and alleviate. 2. Steps taken to debride ulcer: Cleanse with normal saline (NS), apply Santyl, and change dressing daily and as needed. 3. Steps taken to granulate an ulcer with scant drainage: Cleanse with NS, apply hydrogel, and change dressing daily and as needed. 4. Steps taken to granulate an ulcer with moderate drainage: Cleanse with NS, apply calcium alginate, and change dressing daily as needed. B. Patient teaching 1. Educate patient and family regarding the treatment plans for the pressure ulcer. 2. Stress importance of alleviating pressure to the site. Depending on location of the ulcer, provide suggestions to alleviate/offload pressure to the area. C. Pharmaceutical therapy 1. Unless bacterial infection is present, oral antibiotics are not indicated 243 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
with initial wound treatment. Follow-Up A. Follow up in 1 to 2 weeks to evaluate therapy. B. See patients every 1 to 2 weeks until healing well; then patient may reduce to 2-to 4-week evaluation until complete closure. Consultation/Referral A. Consult or refer the patient to a wound care specialist for the following: 1. Extensive ulcer that you are not comfortable treating 2. Patient with multiple medical comorbidities (especially diabetes) 3. Patient not responding to treatment of 2 to 4 weeks 4. Ulcer showing decline on follow-up visit 5. Infection present needing alternative treatment Individual Consideration A. Adults 1. Patients at end-of-life may develop pressure ulcers related to the dying process, referred to as Kennedy terminal ulcers. These patients are treated for comfort. Wounds of the Skin Jill C. Cash and Amy C. Bruggemann Definition A. Wounds are breaks in the external surface of the body. Pathogenesis A. Wounds can be caused by any one of the innumerable objects that breach the skin. Lacerations and abrasions typically heal by a three-stage process of clotting, inflammation, and skin cell proliferation. The most common pathogens of wound infections are Staphylococcus aureus and beta-hemolytic streptococcus. Predisposing Factors 244 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Exposure to accidental or intentional injury B. Accident prevention failure C. High-risk behaviors D. Conditions that predispose to poor wound healing 1. Diabetes 2. Corticosteroid therapy 3. Immunodeficiency 4. Advanced age 5. Undernourishment Common Complaints A. Bleeding B. Pain C. “Cut” in the skin integrity Other Signs and Symptoms A. Signs and symptoms of infection: Deep wounds and dirty wounds have increased risk for infection. B. Soft-tissue damage: Wounds with tissue necrosis have increased risk for infection. Subjective Data A. Elicit the patient's description of how the wound occurred, including where and when the injury was sustained. B. Ascertain how much time elapsed until treatment. If 6 hours have elapsed, bacterial multiplication is likely. C. Ask if the patient is currently immunized for tetanus. D. Complete a drug history; include any allergies to medications, anesthetics, or dressings. E. Ask if the patient is taking any medications, especially steroids, or anticoagulants. F. Assess iodine and sulfa drug allergies before starting treatment. G. Review with the patient whether anything significant in the past medical history may interfere with the healing process (e. g., immunodeficiency, diabetes, etc. ). 245 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Inspect wound. 2. Measure wound for size: Length, width, and depth. Wounds with untidy edges may heal more slowly and with disfigurement. 3. Assess underlying bony structures. 4. Inspect for foreign objects. C. Palpate 1. Palpate extremities for neurovascular function and sensation. 2. Palpate tissue distal to wound. 3. Palpate lymph nodes surrounding injured area. D. Neurologic examination: Assess motor function distal to wound. Diagnostic Tests A. Culture wound site if suspicious of infection. B. Take x-ray films for deep or crushing wounds. Differential Diagnoses A. Wound, minor B. Nonaccidental self-inflicted injury C. Self-inflicted injury D. Domestic violence Plan A. General interventions 1. Wounds that require open-wound management a. Abrasions and superficial lacerations b. Wounds with great amount of tissue damage c. Wounds more than 6 hours old d. Contaminated wounds e. Large area of superficial skin denudation f. Puncture wounds 2. For wounds that do not require sutures: a. Cleanse wound well with normal saline (NS); remove all dirt and 246 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
foreign bodies. b. Forceful irrigation may be needed; use fine-pore sponge (Optipore) with a surfactant such as poloxamer 188 (Shur-Clens). If wound edges easily approximate, apply Steri-Strips. c. Dry, sterile dressings (Telfa, Duoderm, or Opsite) may be used. 3. If inflammation is present, soak and wash for 15 to 20 minutes three to four times per day. Cover with clean, dry dressing. Do not use Steri-Strips. 4. For wounds that require sutures: a. Irrigate with sterile saline solution. b. Anesthetize with 1% to 2% lidocaine (Xylocaine). Do not use solution with epinephrine at fingertips, nose, or ears. Probe wound for any remaining foreign bodies. Approximate wound edges. c. Suture with technique appropriate to site: i. Skin sutures: Nonabsorbable material (e. g., nylon, Prolene, or silk) ii. Subcutaneous and mucosal sutures: Absorbable material (e. g., Dexon, Vicryl, or plain or chromic gut) iii. Extremities: 4-0 nylon iv. Soles of feet: 2--0 nylon d. Cover with clean, dry dressing; change after first 24 hours. e. Suture removal is based on location: i. Head and trunk: 5 to 7 days ii. Extremities: 7 to 10 days iii. Soles and palms: 7 to 10 days iv. Distal extremities: 10 to 14 days f. Tetanus prophylaxis (see Chapter 1, Health Maintenance Guidelines) B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Wound Care: Pressure Ulcers. ” C. Pharmaceutical therapy 1. Control pain with acetaminophen (Tylenol) as needed. 2. Topical antibiotic ointments: Bacitracin and mupirocin 3. Oral antibiotics for prophylaxis a. Amoxicillin, clavulanic acid (Augmentin) i. Adolescents:250 to 500 mg twice daily 247 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
ii. Children:25 to 45 mg/kg/d twice daily for 7 to 10 days; available as 200 mg/5 m L or 400 mg/5 m L liquid b. With penicillin allergy, use erythromycin i. Adolescents: (E-Mycin) 250 mg four times daily for 7 to 10 days ii. Children: (Eryped) 30 to 60 mg/kg/d four times daily for 7 to 10 days; available as 200 mg/5 m L or 400 mg/5 m L liquid. 4. Other alternatives: Cephalexin (Keflex), cefadroxil (Duricef), ciprofloxacin 5. Tetanus toxoid 0. 5 m L by intramuscular (IM) injection in deltoid, if no booster has been administered in the last 5 years Follow-Up A. Have the patient return for evaluation and dressing change in 24 to 48 hours. Consultation/Referral Refer the patient to a physician for wounds of the type listed here. A. Facial wounds B. Subcutaneous tissue penetration C. Functional disturbance of tendons, ligaments, vessels, or nerves D. Grossly contaminated wounds E. Wounds requiring hospitalization or aggressive antimicrobial therapy for evidence of pyogenic abscess, cellulitis, and ascending lymphangitis F. Wounds diagnosed with methicillin-resistant S. aureus should be treated with the following oral antibiotics: Trimethoprim sulfamethoxazole (Bactrim), minocycline or doxycycline, clindamycin, rifampin (should be used in combination with one of the previous antibiotics), and linezolid. Antibiotics that are not recommended because of high resistance include: Beta lactams, fluoroquinolones, dicloxacillin, and cephalexin. Treating the nares with Bactroban ointment twice a day and having the patient use Hibiclens soap for showering will help to prevent recurrent infections. For severe cases of infection, the patient requires hospitalization for aggressive antibiotic treatment. Individual Consideration 248 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Adults with chronic conditions, such as diabetes or immune deficiency, should be monitored closely for infection and delayed wound healing. Xerosis (Winter Itch) Jill C. Cash and Amy C. Bruggemann Definition A. Xerosis, often called “winter itch,” is dry skin. Incidence A. Xerosis occurs in 48% to 98% of patients with atopic dermatitis. B. It occurs more frequently in elderly patients. Pathogenesis A. Dry skin may fissure, appear shiny and cracked, and leave subsequent inflammatory changes. Predisposing Factors A. Frequent bathing with hot water and harsh soaps B. Cold air C. Low humidity D. Central heating or cooling E. Alcohol use F. Poor nutrition G. Cholesterol-lowering drugs H. Systemic disease manifested by thyroid, renal, or hepatic disease; anemia; diabetes; or malignancy Common Complaint A. Dry, rough skin, especially on legs Other Signs and Symptoms A. Pruritic, scaling skin, particularly on legs, with cracks and/or fissures B. Pruritus may be associated with systematic disorders or other infections. 249 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Itching of scabies is particularly intense at night. C. Plaques 2 to 5 cm in diameter D. Erythema E. Wheal-and-flare response typical of urticaria Subjective Data A. Obtain the patient's description of the onset of symptoms and whether it was sudden or gradual. B. Ask the patient to identify any discomfort. Ask if the skin is itchy or painful. C. Assess lesions for any associated discharge (blood or pus). D. Determine whether the patient has recently ingested any new medicines (antibiotics, cholesterol-lowering medications, or other drugs), alcohol, or new foods. E. Ask the patient about use of any topical medications. F. Identify any preceding systemic symptoms (fever, sore throat, anorexia, or vaginal discharge). G. Ask the patient about bathing in hot water and if patient is bathing regularly. H. Review the patient's full medication history for comorbid conditions. Physical Examination A. Inspect: Inspect skin for lesions, noting texture of skin. B. Palpate 1. Palpate abdomen for masses and hepatosplenomegaly. 2. Palpate lymph nodes. Diagnostic Test A. There are no diagnostic tests for xerosis. Differential Diagnoses A. Xerosis B. Scabies C. Atopic dermatitis Plan 250 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. General interventions 1. Hydrate and lubricate the skin. 2. Assess for and treat secondary infection. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “Xerosis (Winter Itch). ” 2. Avoid alkaline soaps: Use Dove, Basis, mild soap, or soap substitute such as Cetaphil or Aquanil. C. Pharmaceutical therapy 1. Apply emollient cream or lotion (Sarna, Lac-Hydrin, or Eucerin). 2. Use over-the-counter (OTC) skin lubricants (petroleum jelly, mineral oil, or cold cream). 3. Topical corticosteroid a. Triamcinolone 0. 025% two to four times daily or 0. 1% two to three times daily; apply sparingly. b. Hydrocortisone 1% or 2. 5% two to four times daily; apply thin film, avoid face. 4. Systemic antihistamine is used to control pruritus, such as diphenhydramine (Benadryl) 25 to 50 mg every 4 to 6 hours as needed Follow-Up A. Follow up as indicated until resolved. Consultation/Referral A. Consult or refer the patient to a dermatologist if no improvement is seen. Individual Considerations A. Pediatrics: Avoid corticosteroid preparation or use low-potency corticosteroid only. B. Geriatrics: Monitor the patient for possible skin breakdown and/or ulceration. Bibliography Aziz, H., Rhee, P., Pandit, V., Tang, A., Gries, L., & Joseph, B. (2015). The current concepts in 251 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
management of animal (dog, cat, snake, scorpion) and human bite wounds. Journal of Trauma and Acute Care Surgery, 78(3), 641-648. Baranoski, S., & Ayello, E. (2015). Wound care essentials: Practice principle. Philadelphia, PA: Lippincott Williams, and Wilkins. Blereau, R. P. (2012). Acneiform folliculitis. Consultant (00107069), 52(6),469. Brackenbury, J. (2016). Recommended topical treatments for managing adult acne in women. Nurse Prescribing, 14(3), 126-129. Centers for Disease Control and Prevention. (2013). Genital herpes—CDC fact sheet. Retrieved from https://www. cdc. gov/std/herpes/STDFact-Herpes. htm Centers for Disease Control and Prevention. (2016, August 19). Shingles (herpes zoster). Retrieved from https://www. cdc. gov/shingles Clancy, C. J., & Nguyen, M. H. (2012). The end of an era in defining the optimal treatment of invasive candidiasis. Clinical Infectious Diseases, 54(8), 1123-1125. Collins, L., & Seraj, S. (2010). Diagnosis and treatment of venous ulcers. American Family Physician, 81(8), 989-996. Derby, R., Rohal, P., Jackson, C., Beutler, A., & Olsen, C. (2011). Novel treatment of onychomycosis using over-the-counter mentholated ointment: A clinical case series. Journal of the American Board of Family Medicine, 24(1),69-74. Eichenfield, L. F., Tom, W. L., Berger, T. G., Krol, A., Paller, A. S., Schwarzenberger, K.,... Sidbury, R. (2014). Guidelines of care for the management of atopic dermatitis: Section 2. Management and treatment of atopic dermatitis with topical therapies. Journal of the American Academy of Dermatology, 71(1), 116-132. Ellis, R., & Ellis, C. (2014). Dog and cat bites. American Family Physician, 90(4), 239-243. Ely, J. W., Rosenfeld, S., & Seabury Stone, M. (2014). Diagnosis and management of tinea infections. American Family Physician, 90(10), 702-710. Gagliardi, A. M. Z., Andriolo, B. N. G., Torloni, M. R., & Soares, B. G. O. (2016). Vaccines for preventing herpes zoster in older adults. Cochrane Database of Systematic Reviews, 2016 (3). doi/:10. 1002/14651858. CD008858. pub3 Gaston, R., & Lewis, D. R. (2010). Animal bites to the hand. Current Orthopaedic Practice, 21 (6), 559-563. Gunning, K., Pippitt, K., Kiraly, B., & Sayler, M. (2012). Pediculosis and scabies: Treatment update. American Family Physician, 86(6), 535-541. Habif, T. P. (Ed. ). (2011). Skin disease diagnosis and treatment (3rd ed. ). Philadelphia, PA: Saunders Elsevier. Hartman-Adams, H., Banvard, C., & Juckett, G. (2014). Impetigo: Diagnosis and treatment. American Family Physician, 90(4), 229-235. Iavazzo, C., Gkegkes, I. D., Zarkada, I. M., & Falagas, M. E. (2011). Boric acid for recurrent vulvovaginal candidiasis: The clinical evidence. Journal of Women's Health (2002), 20(8), 1245-1255. Kennedy, K. (2016). Understanding the Kennedy terminal ulcer. Retrieved from http://www. kennedyterminalulcer. com Martinez-Diaz, G., & Mancini, A. (2010). CNE series. Head lice: Diagnosis and therapy. Dermatology Nursing, 22(4),2-8. Monroe, J. (2012). Papules and plaques from head to foot. Journal of the American Academy of Physician Assistants, 25(9),16. Moore, S. J., Mordue Luntz, A. J., & Logan, J. G. (2012). Insect bite prevention. Infectious Disease Clinics of North America, 26(3), 655-673. Mounsey, K. E., & Mc Carthy, J. S. (2013). Treatment and control of scabies. Current Opinion in 252 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Infectious Diseases, 26(2), 133-139. National Clearing House Guidelines. (2001). Guidelines of care for the management of primary cutaneous melanoma (revised 2011 November) NGC:009038. Rockville, MD: American Academy of Dermatology-Medical Specialty Society. National Pressure Ulcer Advisory Panel. (2016, April 13). Pressure injury staging. Retrieved from http://www. npuap. org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers; clinical practice guideline. Washington, DC: Author. Nutten, S. (2015). Atopic dermatitis: Global epidemiology and risk factors. Annals of Nutrition & Metabolism, 66(Suppl. 1),8-16. Oge, L. K., Muncie, L. H., & Phillips, A. R. (2015). Rosacea: Diagnosis and treatment. American Family Physician, 92(3) 187-196. Plaza, J. A., &Prieto, V. G. (2013). Erythema multiforme. Medscape Retrieved from http://emedicine. medscape. com/article/1122915-overview Radley, K. (2015). The management and treatment of acnes. Primary Health Care, 25(4),34-41. Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing pressure ulcers: A systematic review. The Journal of the American Medical Association, 296(8), 974-984. Rubenstein, R., & Malerich, S. (2014). Malassezia (pityrosporum) folliculitis. Journal of Clinical Aesthetic Dermatology, 7(4), 37-41. Sankararaman, S., & Velayuthan, S. (2014). Multiple recurrences in pityriasis rosea—A case report with review of the literature. Indian Journal of Dermatology, 59(3),316. Selden, S. (2012). Seborrheic dermatitis. Medscape. Retrieved from http://emedicine. medscape. com/article/1108312-overview Shah, J., Sheffield, P., & Fife, C. (2011). Wound care certification: Study guide. Flagstaff, AZ: Best Publishing. Sokumbi, O., & Wetter, D. A. (2012). Clinical features, diagnosis, and treatment of erythema multiforme: A review for the practicing dermatologist. International Journal of Dermatology, 51(8), 889-902. Thakral, G., La Fontaine, J., Kim, P., Najafi, B., Nichols, A., & Lavery, L. A. (2015). Treatment options for venous leg ulcers: Effectiveness of vascular surgery, bioengineered tissue, and electrical stimulation. Advances in Skin & Wound Care, 28(4), 164-172. Thompson, D. L., & Thompson, M. J. (2014). Knowledge, instruction and behavioural change: Building a framework for effective eczema education in clinical practice. Journal of Advanced Nursing, 70(11), 2483-2494. Titus, S., & Hodge, J. (2012). Diagnosis and treatment of acne. American Family Physician, 86(8), 734-740. Van Onselen, J. (2012). Rosacea: Symptoms and support. British Journal of Nursing (Mark Allen Publishing), 21(21), 1252-1255. Vandiver, A., & Cohe, B. A. (2016). Vesicular rash in an infant with eczema. Contemporary Pediatrics, 33(6),38-40. Watkins, J. (2010). Treating shingles (herpes zoster) in the older person. British Journal of Community Nursing, 15(9), 420, 422, 424 passim. Watkins, J. (2011). Eczema diagnosis and management in the community. British Journal of Community Nursing, 16(9), 418, 420, 422. Watkins, J. (2012). Problems with acne vulgaris in adolescence. Practice Nursing, 23(11), 562-565. Weigle, N., & Mc Bane, S. (2013). Psoriasis. American Family Physician, 87(9), 626-633. Williams, H. C., Dellavalle, R. P., & Garner, S. (2012). Acne vulgaris. Lancet (London, England), 379(9813), 361-372. 253 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Wilson, J. F. (2011). In the clinic. Herpes zoster. Annals of Internal Medicine, 154(5), ITC31-15; quiz ITC316. Wyndham, M. (2011). Pityriasis rosea. Practice Nurse, 41(1),41. 254 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
5Eye Guidelines Amblyopia Jill C. Cash and Nancy Pesta Walsh Definition A. Amblyopia is a decrease in the visual acuity of one eye. It is commonly seen in young children and cannot be corrected with either glasses or contact lenses. Incidence A. Amblyopia is most commonly diagnosed in children and occurs in approximately 2. 5% of the population. B. Most common cause of childhood vision loss. Pathogenesis Amblyopia has numerous causes, including: A. Congenital defect B. Develops from a corneal scar or cataract C. Occurs from an uncorrected high refractive error, which causes visual blurring D. Develops when each eye has a different refractive error that leads to blurred vision E. Strabismic amblyopia may also occur due to the loss of vision in the eye that turns inward or outward. Predisposing Factors 255 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. One parent with amblyopia B. Prematurity C. Small for gestational dates D. Maternal smoking or alcohol use Common Complaints A. Decreased vision—complains of sitting close to the TV, sitting in the front row of a classroom, having trouble seeing the ball in sports, and so on B. Vision that is not corrected with either glasses or contact lenses C. Wandering eye and frequent eye squinting Other Signs and Symptoms A. Frequent rubbing of the eyes B. Tired eyes Subjective Data A. Elicit the onset of visual changes, noting course of symptoms and severity. B. Assess for pain or any new injury or trauma to the eye. C. Inquire about new events or changes in health history, including contact lenses, glasses, illnesses, and cataracts. D. Review patient and family history of amblyopia. Physical Examination A. Inspect eyes 1. Note extraocular movements (EOMs) of eyes. 2. Examine sclera, pupil, iris, and fundus. 3. Examine eyes for red reflex. B. Assess vision based on age, using LEA SYMBOLS®, Sloan letters, Sloan numerals, Tumbling E, and the HOTV. The Kindergarten Eye Chart and the Snellen chart are less preferred methods, as they do not meet the World Health Organization/Committee on Vision Standards. C. Visual fields may be assessed with a parent holding the child in his or her lap. Diagnostic Test 256 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. None Differential Diagnoses A. Amblyopia B. Organic brain lesion Plan A. General interventions 1. All children need to have a visual examination prior to starting school. 2. Recommend examination by an ophthalmologist for children with strabismus and for those with a family history of amblyopia. 3. Measures for refractive correction or patching of the stronger eye are usually performed to encourage the weak eye to develop. 4. Surgery may be required for abnormal positioning of the eye. Follow-Up A. Follow-up with an ophthalmologist. Consultation/Referral A. Refer the patient to an ophthalmologist for evaluation and treatment. Individual Consideration A. None Blepharitis Jill C. Cash and Nancy Pesta Walsh Definition A. Blepharitis is dryness and flaking of the eyelashes, resulting from an inflammatory response of the eyelid. Incidence A. The exact incidence is not known; however, blepharitis is one of the most commonly seen eye conditions. 257 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Pathogenesis A. Seborrheic: Excessive shedding of skin cells and blockage of glands B. Staphylococcus: Most common bacteria found, responsible for bacterial infection of lid margin C. Commonly seen with inadequate flow of oil and mucus into the tear duct Predisposing Factors A. Diabetes B. Candida C. Seborrheic dermatitis D. Acne rosacea Common Complaints A. Burning and itching B. Lacrimal tearing C. Photophobia D. Recurrent eye infections, styes, or chalazions E. Dry, flaky secretions on lid margins and eyelashes F. Dry eyes Other Signs and Symptoms A. Seborrheic blepharitis: Lid margin swelling and erythema, flaking, nasolabial erythema, and scaling B. Staphylococcus aureus blepharitis: Erythema/edema, scaling, burning, tearing, itching, and recurrent stye or chalazia C. Meibomian gland dysfunction: Prominent blood vessels crossing the mucocutaneous junction, frothy discharge along eyelid margin, thick discharge, and chalazion; may have rosacea or seborrheic dermatitis D. May have dandruff of scalp and eyebrows Subjective Data A. Elicit onset and duration of signs and symptoms. B. Note sensations of itching, burning, or pain in the eye. C. Ask: What makes signs and symptoms worse? What makes signs and symptoms better? 258 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Any change in soaps, creams, lotions, or shampoos? E. Has the patient had similar signs and symptoms in the past? F. Note any visual change or pain since the last eye examination. G. Note contributing factors involved, if present. Physical Examination A. Inspection 1. Inspect eyes, noting extraocular movements (EOMs) of eyes. 2. Examine sclera, pupil, iris, and fundus. 3. Examine eyes for red reflex. 4. Note erythema or edema on lid margin; note dryness, scaling, and flakes. 5. Assess vision based on age, using Snellen chart for children older than 3 years. 6. Visual fields may be assessed with a parent holding the child in his or her lap. Diagnostic Test A. None Differential Diagnoses A. Blepharitis 1. S. aureus 2. Seborrheic 3. Meibomian gland dysfunction B. Conjunctivitis C. Squamous cell carcinoma D. Stye E. Upper respiratory infection F. Sinusitis Plan A. General interventions 1. Assess patient and rule out bacterial infection and vision changes. 2. When examining a child, notify the parent of diagnosis and educate the parent regarding findings. 259 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Patients with recurrent blepharitis need further follow-up. B. Patient teaching 1. Wash eye with antibacterial soap and water. May use gentle baby shampoo. 2. Apply warm compresses to the eye for comfort daily for approximately 10 to 20 minutes. 3. Stop use of contacts until the eye is healed. 4. Encourage good hygiene for prevention of recurrent episodes. C. Pharmaceutical therapy 1. Apply bacitracin or erythromycin ophthalmic ointment to the margin of the eye at bedtime, taking care not to contaminate the medication bottle. 2. Oral antibiotics: Tetracycline 250 mg by mouth, four times a day, or doxycycline 100 mg by mouth, twice a day, tapering after clinical improvement, for a total of 2 to 6 weeks. Alternative: Erythromycin 250 to 500 mg daily or azithromycin 250 to 500 mg one to three times a week for 3 weeks. 3. Consider long-term treatment with doxycycline, if infections reoccur. Follow-Up A. Recommend follow-up with a primary provider in 1 to 2 weeks. B. Consider referral to an eye specialist for recurrent episodes of blepharitis and for slit-lamp examination. Individual Considerations A. Pediatrics: Tetracycline is not recommended for children younger than 8 years. B. Pregnant or lactating women: Tetracycline is not recommended. C. Azithromycin may lead to abnormalities of heart electrical rhythm; use with caution in patients with a high risk of cardiovascular disease. Cataracts Jill C. Cash and Nancy Pesta Walsh Definition 260 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. A cataract, opacity of the crystalline lens of the eye, causes progressive, painless loss of vision (functional impairment). Presenile and senile cataract formation is painless and progresses throughout months and years. Cataracts are frequently associated with intraocular inflammation and glaucoma. Incidence A. Cataracts are the most common cause of blindness in the world. B. Ninety-five percent of people older than 60 years have cataracts without visual disturbance. C. Fifty percent of people older than 40 years have significant visual loss due to cataracts. Pathogenesis A. Age-related changes of the lens of the eye result from protein accumulation, which produces a fibrous thickened lens that obscures vision. Predisposing Factors A. Age B. Trauma C. Medications (e. g., topical or systemic steroids, major tranquilizers, or some diuretics) D. Medical diseases (e. g., diabetes mellitus, Wilson's disease, hypoparathyroidism, glaucoma, congenital rubella syndrome, chronic anteri, or uveitis) E. Chronic exposure to ultraviolet (UV) B light F. Alcohol use G. Family history H. Prior intraocular surgery I. Obesity J. Smoking Common Complaints A. Decreased vision B. Blurred or foggy vision, “ghost” images C. Inability to drive at night 261 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Other Signs and Symptoms A. Initial visual event can be a shift toward nearsightedness. B. Visual impairment can be more marked at distances, with abnormal visual acuity examinations. C. Severe difficulty with glare can occur. D. Altered color perception may be noticed. E. Frequent falls or injuries may occur. Subjective Data A. Review the onset, course, and duration of visual changes, including altered day or night vision and nearsighted versus farsighted vision. B. Assess whether involvement is in one or both eyes. C. Determine what improves vision—use of glasses or use of extra light. D. Review the patient's medical history and current medications. E. Review the patient's history for traumatic injury. F. Discuss the patient's occupation and leisure activities to determine exposure to UV rays. Physical Examination A. Inspect 1. Conduct a funduscopic examination. a. Check red reflex and opacity. i. A bright red reflex is seen in the normal eye. ii. Cataract formation is seen by the disruption of the red reflex. iii. Lens opacities appear as dark areas against the background of the red-orange reflex. b. Examine color of opacity. For brunescent cataracts, the nucleus acquires a yellow-brown coloration and becomes progressively more opaque. c. Check retinal abnormalities, hemorrhage, scarring, and drusen (small yellow deposits). Diagnostic Tests A. Perform visual acuity examination. B. Perform peripheral vision examination. 262 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Perform slit-lamp examination to determine the exact location and type of cataract. D. Dilated eye examination. Differential Diagnoses A. Cataracts B. Glaucoma C. Age-related macular degeneration (macular degeneration causes vision loss that is symptomatically similar to cataracts) D. Diabetic retinopathy E. Temporal arteritis Plan A. General interventions 1. Monitor the patient for increased interference of visual impairment on his or her lifestyle. 2. Cataracts do not need to be removed unless there is impairment of normal, everyday activities. 3. Surgery is the definitive treatment; however, modification of glasses may improve vision adequately to defer surgery. Contact lenses are optically superior to glasses. B. Patient teaching 1. Prevention is important. Teach the patient to use protective eyewear to prevent trauma. 2. Use sunglasses to prevent the penetration of UV B rays. 3. Wear a hat with a visor to protect eyes when outdoors. Follow-Up A. Surgical removal is indicated if the visual disturbance is interfering with the patient's life, such as causing falls or prohibiting reading. Consultation/Referral A. Refer patient for ophthalmologic consultation. B. Patients should be followed by an ophthalmologist to monitor the cataract for increased size and progressive visual impairment. C. Contact a social worker or community resources as needed. 263 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Chalazion Jill C. Cash and Nancy Pesta Walsh Definition A. Chalazion is a chronic lipogranulomatous inflammation of a meibomian gland located in the eyelid margin. Inflammation occurs from occlusion of the ducts. Incidence A. Commonly seen, though the incidence is unknown. Pathogenesis A. Meibomian glands secrete the oil layer of the tear film that covers the eye. When the glands become blocked, the oil or lipid extrudes into the surrounding tissue, causing the formation of a nodule. Predisposing Factor A. Chalazion may occur as a secondary infection of the surrounding tissues. Common Complaints A. Swelling, nontender palpable nodule, usually pea-sized, inside lid margin or eye B. Discomfort or irritation due to swelling Other Signs and Symptoms A. Tearing B. Feeling of a foreign body in the eye C. If infection is present, the entire lid becomes painfully swollen Subjective Data A. Review the onset of symptoms, their course and duration, and any concurrent visual disturbance. B. Question the patient regarding possible foreign body or trauma to the eye. C. Elicit the quality of pain or tenderness of the eyelid. D. Review the past eye problems and the treatment received. 264 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Temperature B. Inspect 1. Inspect the eye, sclera, and conjunctiva for a foreign body. 2. Check for red-or gray-colored subconjunctival mass. C. Palpate 1. Palpate the eyelid for masses and tenderness. Usually a hard, nontender nodule is found on the middle portion of the tarsus, away from the lid border; it may develop on the lid margin if the opening of the duct is involved. Some chalazia continue to increase in size and can cause astigmatism by putting pressure on the eye globe. 2. Chalazia may become acutely tender; however, note the difference between the chalazia and the stye, which is found on the lid margin. 3. Check for preauricular adenopathy. Diagnostic Test A. Perform visual acuity examination. Differential Diagnoses A. Chalazion B. Chronic dacryocystitis C. Hordeolum (Stye) D. Blepharitis E. Xanthelasma F. Cellulitis of the eyelid Plan A. General interventions 1. Small chalazia, usually, do not require treatment. 2. Warm, moist compresses may be applied for 15 minutes four times a day. B. Patient teaching: Instruct patient regarding compresses and handwashing. C. Pharmaceutical therapy 1. Sulfacetamide sodium (Sulamyd) ophthalmic ointment 10%, four times daily, for 7 days for bacterial infection 265 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |